Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study.

AIM: To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction. DESIGN: Mixed-methods study describing the development of a patient decision aid. SETTING: A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids. PARTICIPANTS: People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group. PRIMARY AND SECONDARY OUTCOMES: Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis. RESULTS: We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms. CONCLUSION: Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted.

RECITAL: a non-inferiority randomised control trial evaluating a virtual fracture clinic compared with in-person care for people with simple fractures (study protocol).

INTRODUCTION: Most simple undisplaced fractures can be managed without surgery by immobilising the limb with a splint, prescribing medication for pain, and providing advice and early rehabilitation. Recent systematic reviews based on retrospective observational studies have reported that virtual fracture clinics can deliver follow-up care that is safe and cost-effective. However, no randomised controlled trial has investigated if a virtual fracture clinic can provide non-inferior physical function outcomes compared with an in-person clinic for patients with simple fractures. METHODS AND ANALYSIS: 312 participants will be recruited from 2 metropolitan hospitals located in Sydney, Australia. Adult patients will be eligible if they have an acute simple fracture that can be managed with a removable splint and is deemed appropriate for follow-up at either the virtual or in-person fracture clinic by an orthopaedic doctor. Patients will not be eligible if they have a complex fracture that requires a cast or surgery. Eligible participants will be randomised to receive their follow-up care either at the virtual or the in-person fracture clinic. Participants at the virtual fracture clinic will be reviewed within 5 days of receiving a referral through video calls with a physiotherapist. Participants at the in-person fracture clinic will be reviewed by an orthopaedic doctor within 7-10 days of receiving a referral. The primary outcome will be the patient's function measured using the Patient-Specific Functional Scale at 12 weeks. Secondary outcomes will include health-related quality of life, patient-reported experiences, pain, health cost, healthcare utilisation, medication use, adverse events, emergency department representations and surgery. ETHICS AND DISSEMINATION: The study has been approved by the Sydney Local Health District Ethics Review Committee (RPAH Zone) (X23-0200 and 2023/ETH01038). The trial results will be submitted for publication in a reputable international journal and will be presented at professional conferences. TRIAL REGISTRATION NUMBER: ACTRN12623000934640.

Can language enhance physical therapists' willingness to follow Choosing Wisely recommendations? A best-worst scaling study.

BACKGROUND: Choosing Wisely recommendations could reduce physical therapists' use of low-value care. OBJECTIVE: To investigate whether language influences physical therapists' willingness to follow the Australian Physiotherapy Association's (APA) Choosing Wisely recommendations. DESIGN: Best-worst Scaling survey METHODS: The six original APA Choosing Wisely recommendations were modified based on four language characteristics (level of detail, strength- qualified/unqualified, framing, and alternatives to low-value care) to create 60 recommendations. Physical therapists were randomised to a block of seven choice tasks, which included four recommendations. Participants indicated which recommendation they were most and least willing to follow. A multinomial logistic regression model was used to create normalised (0=least preferred; 10=most preferred) and marginal preference scores. RESULTS: 215 physical therapists (48.5% of 443 who started the survey) completed the survey. Participants' mean age (SD) was 38.7 (10.6) and 47.9% were female. Physical therapists were more willing to follow recommendations with more detail (marginal preference score of 1.1) or that provided alternatives to low-value care (1.3) and less willing to follow recommendations with negative framing (-1.3). The use of qualified ('don't routinely') language (vs. unqualified - 'don't') did not affect willingness. Physical therapists were more willing to follow recommendations to avoid imaging for non-specific low back pain (3.9) and electrotherapy for low back pain (3.8) vs. recommendation to avoid incentive spirometry after upper abdominal and cardiac surgery. CONCLUSION: Physical therapists were more willing to follow recommendations that provided more detail, alternatives to low-value care, and were positively framed. These findings can inform the development of future Choosing Wisely recommendations and could help reduce low-value physical therapy.

Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study.

OBJECTIVE: To develop and user-test a patient decision aid portraying the benefits and harms of non-surgical management and surgery for Achilles tendon ruptures. DESIGN: Mixed methods. SETTING: A draft decision aid was developed using guidance from a multidisciplinary steering group and existing patient decision aids. Participants were recruited through social media. PARTICIPANTS: People who have previously sustained an Achilles tendon rupture and health professionals who manage these patients. PRIMARY AND SECONDARY OUTCOMES: Semi-structured interviews and questionnaires were used to gather feedback on the decision aid from health professionals and patients who had previously suffered an Achilles tendon rupture. The feedback was used to redraft the decision aid and assess acceptability. An iterative cycle of interviews, redrafting according to feedback and further interviews was used. Interviews were analysed using reflexive thematic analysis. Questionnaire data were analysed descriptively. RESULTS: We interviewed 18 health professionals (13 physiotherapists, 3 orthopaedic surgeons, 1 chiropractor, 1 sports medicine physician) and 15 patients who had suffered an Achilles tendon rupture (median time since rupture was 12 months). Most health professionals and patients rated the aid's acceptability as good-excellent. Interviews showcased agreement among health professionals and patients on most aspects of the decision aid: introduction, treatment options, comparing benefits and harms, questions to ask health professionals and formatting. However, health professionals had differing views on details about Achilles tendon retraction distance, factors that modify the risk of harms, treatment protocols and evidence on benefits and harms. CONCLUSION: Our patient decision aid is an acceptable tool to both patients and health professionals, and our study highlights the views of key stakeholders on important information to consider when developing a patient decision aid for Achilles tendon rupture management. A randomised controlled trial evaluating the impact of this tool on the decision-making of people considering Achilles tendon surgery is warranted.

How do people perceive different advice for rotator cuff disease? A content analysis of qualitative data collected in a randomised experiment.

OBJECTIVES: To explore how people perceive different advice for rotator cuff disease in terms of words/feelings evoked by the advice and treatment needs. SETTING: We performed a content analysis of qualitative data collected in a randomised experiment. PARTICIPANTS: 2028 people with shoulder pain read a vignette describing someone with rotator cuff disease and were randomised to: bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation emphasised that treatment is needed for recovery. PRIMARY AND SECONDARY OUTCOMES: Participants answered questions about: (1) words/feelings evoked by the advice; (2) treatments they feel are needed. Two researchers developed coding frameworks to analyse responses. RESULTS: 1981 (97% of 2039 randomised) responses for each question were analysed. Guideline-based advice (vs treatment recommendation) more often elicited words/feelings of reassurance, having a minor issue, trust in expertise and feeling dismissed, and treatment needs of rest, activity modification, medication, wait and see, exercise and normal movements. Treatment recommendation (vs guideline-based advice) more often elicited words/feelings of needing treatment/investigation, psychological distress and having a serious issue, and treatment needs of injections, surgery, investigations, and to see a doctor. CONCLUSIONS: Words/feelings evoked by advice for rotator cuff disease and perceived treatment needs may explain why guideline-based advice reduces perceived need for unnecessary care compared to a treatment recommendation.

Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews.

OBJECTIVE: To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition. DESIGN: Overview of systematic reviews. DATA SOURCES: PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Systematic reviews comparing any antidepressant with placebo for any pain condition in adults. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework. RESULTS: 26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference -5.3, 95% confidence interval -7.3 to -3.3), postoperative pain (-7.3, -12.9 to -1.7), neuropathic pain (-6.8, -8.7 to -4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons). CONCLUSIONS: Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews-seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022311073.

The effect of almond intake on cardiometabolic risk factors, inflammatory markers, and liver enzymes: A systematic review and meta-analysis.

Almond intake may be correlated with improvements in several cardiometabolic parameters, but its effects are controversial in the published literature, and it needs to be comprehensively summarized. We conducted a systematic search in several international electronic databases, including MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until April 2021 to identify randomized controlled trials that examined the effects of almond consumption on cardiometabolic risk factors, inflammatory markers, and liver enzymes. Data were pooled using the random-effects model method and presented as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Twenty-six eligible trials were analyzed (n = 1750 participants). Almond intake significantly decreased diastolic blood pressure, total cholesterol, triglyceride, low-density lipoprotein (LDL), non-high-density lipoprotein (HDL), and very LDL (p < 0.05). The effects of almond intake on systolic blood pressure, fasting blood glucose, insulin, hemoglobin A1c, homeostatic model assessment of insulin resistance, C-peptide, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, C-reactive protein (CRP), hs-CRP (high sensitivity C-reactive protein), interleukin 6, tumor necrosis factor-α, ICAM (Intercellular Adhesion Molecule), VCAM (Vascular Cell Adhesion Molecule), homocysteine, HDL, ox-LDL, ApoA1, ApoB, and lipoprotien-a were not statistically significant (p > .05). The current body of evidence supports the ingestion of almonds for their beneficial lipid-lowering and antihypertensive effects. However, the effects of almonds on antiinflammatory markers, glycemic control, and hepatic enzymes should be further evaluated via performing more extensive randomized trials.

Public and patient perceptions of diagnostic labels for non-specific low back pain: a content analysis.

PURPOSE: An online randomised experiment found that the labels lumbar sprain, non-specific low back pain (LBP), and episode of back pain reduced perceived need for imaging, surgery and second opinions compared to disc bulge, degeneration, and arthritis among 1447 participants with and without LBP. They also reduced perceived seriousness of LBP and increased recovery expectations. METHODS: In this study we report the results of a content analysis of free-text data collected in our experiment. We used two questions: 1. When you hear the term [one of the six labels], what words or feelings does this make you think of? and 2. What treatment (s) (if any) do you think a person with [one of the six labels] needs? Two independent reviewers analysed 2546 responses. RESULTS: Ten themes emerged for Question1. Poor prognosis emerged for disc bulge, degeneration, and arthritis, while good prognosis emerged for lumbar sprain, non-specific LBP, and episode of back pain. Thoughts of tissue damage were less common for non-specific LBP and episode of back pain. Feelings of uncertainty frequently emerged for non-specific LBP. Twenty-eight treatments emerged for Question2. Surgery emerged for disc bulge, degeneration, and arthritis compared to lumbar sprain, non-specific LBP, and episode of back pain. Surgery did not emerge for non-specific LBP and episode of back pain. CONCLUSION: Our results suggest that clinicians should consider avoiding the labels disc bulge, degeneration and arthritis and opt for labels that are associated with positive beliefs and less preference for surgery, when communicating with patients with LBP.

Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment.

QUESTION: What are the effects of diagnostic labels and advice, and interactions between labels and advice, on perceived need for shoulder surgery for rotator cuff disease? DESIGN: 2×2 factorial online randomised experiment. PARTICIPANTS: People with shoulder pain. INTERVENTION: Participants read a scenario describing a patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery. OUTCOME MEASURES: Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work. RESULTS: A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect -0.5 on a 0-to-10 scale, 98.3% CI -0.7 to -0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect -1.0, 98.3% CI -1.3 to -0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome. CONCLUSION: Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition). TRIAL REGISTRATION: ACTRN12621001370897.

The impact of a patient decision aid on intention to undergo surgery for subacromial pain syndrome: An online randomised controlled trial.

OBJECTIVE: To evaluate the effects of a patient decision aid for people considering shoulder surgery. METHODS: Participants with shoulder pain considering shoulder surgery (n = 425) were recruited online and randomised to (i) a decision aid outlining the benefits and harms of shoulder surgery and non-surgical options (then randomised to a side-by-side vs. top-and-bottom display of options); and (ii) general information about shoulder pain from the NHS. Outcomes included treatment intention (primary), knowledge, attitudes, informed choice, and decisional conflict. Linear and logistic regression models were used to evaluate between-groups differences in outcomes. RESULTS: 409 participants (96%) had post-intervention data. Mean age was 41.3 years, 44.2% were female. There was no between-group difference in post-intervention treatment intention (MD -0.2, 95% CI: -3.3 to 2.8) and likelihood of intending to have shoulder surgery (OR 0.7, 95% CI: 0.3-1.5). The decision aid slightly improved knowledge (MD 4.4, 95% CI: 0.2-8.6), but not any other secondary outcomes. The display of options did not influence any outcome. CONCLUSIONS: In this online trial, a co-designed patient decision aid had no effect on treatment intention, attitudes, informed choice, and decisional conflict, but a small effect on improving knowledge. PRACTICE IMPLICATIONS: Research is needed to understand reasons for the lack of anticipated effects. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ACTRN12621000992808).

Effect of diagnostic labelling on management intentions for non-specific low back pain: A randomized scenario-based experiment.

BACKGROUND: Diagnostic labels may influence treatment intentions. We examined the effect of labelling low back pain (LBP) on beliefs about imaging, surgery, second opinion, seriousness, recovery, work, and physical activities. METHODS: Six-arm online randomized experiment with blinded participants with and without LBP. Participants received one of six labels: 'disc bulge', 'degeneration', 'arthritis', 'lumbar sprain', 'non-specific LBP', 'episode of back pain'. The primary outcome was the belief about the need for imaging. RESULTS: A total of 1375 participants (mean [SD] age, 41.7 years [18.4 years]; 748 women [54.4%]) were included. The need for imaging was rated lower with the labels 'episode of back pain' (4.2 [2.9]), 'lumbar sprain' (4.2 [2.9]) and 'non-specific LBP' (4.4 [3.0]) compared to the labels 'arthritis' (6.0 [2.9]), 'degeneration' (5.7 [3.2]) and 'disc bulge' (5.7 [3.1]). The same labels led to higher recovery expectations and lower ratings of need for a second opinion, surgery and perceived seriousness compared to 'disc bulge', 'degeneration' and 'arthritis'. Differences were larger amongst participants with current LBP who had a history of seeking care. No differences were found in beliefs about physical activity and work between the six labels. CONCLUSIONS: 'Episode of back pain', 'lumbar sprain' and 'non-specific LBP' reduced need for imaging, surgery and second opinion compared to 'arthritis', 'degeneration' and 'disc bulge' amongst public and patients with LBP as well as reducing the perceived seriousness of LBP and enhancing recovery expectations. The impact of labels appears most relevant amongst those at risk of poor outcomes (participants with current LBP who had a history of seeking care).

Physical therapy utilization, costs, and return-to-work status following lumbar spine surgery: A retrospective analysis of workers compensation claims in Australia.

BACKGROUND: No study to our knowledge has explored physical therapy utilization following lumbar spine surgery in a workers' compensation setting. OBJECTIVES: Describe physical therapy utilization and costs, and return-to-work status in patients following lumbar spine surgery under a workers' compensation claim. METHODS: Using data from the New South Wales (NSW) State Insurance Regulatory Authority (Australia), we audited physical therapy billing codes for patients who received lumbar spine surgery from 2010 to 2017. We summarised, by fusion versus decompression, the number of physical therapy sessions patients received up to 12 months post-operatively, total cost of physical therapy and time to initiation of physical therapy. Number of physical therapy sessions and physical therapy utilization at 12 months were summarised by return-to-work status at 12 months. RESULTS: We included 3524 patients (1220 had fusion; 2304 decompression). On average, patients received 22 ± 22 physical therapy sessions to 12 months post-operatively (mean cost=AU$1902, US$1217); 24% were receiving physical therapy at 12 months. Most had 9-24 (31%) or 25-50 sessions (25%); 11% had > 50 sessions, whereas 11% had no physical therapy. Patients who had fusion (compared to decompression) had more physical therapy and incurred higher physical therapy costs. Time post-surgery to initiate physical therapy increased from 2010 to 2017. Patients with > 50 sessions and still having physical therapy by 12 months were least likely to be working. CONCLUSIONS: For most patients, physical therapy utilization following lumbar spine surgery aligns with the best available evidence. However, some patients may be receiving too much physical therapy or initiating physical therapy too early.

How do people perceive different labels for rotator cuff disease? A content analysis of data collected in a randomised controlled experiment.

OBJECTIVES: Explore how people perceive different labels for rotator cuff disease in terms of words or feelings evoked by the label and treatments they feel are needed. SETTING: We performed a content analysis of qualitative data collected in a six-arm, online randomised controlled experiment. PARTICIPANTS: 1308 people with and without shoulder pain read a vignette describing a patient with rotator cuff disease and were randomised to one of six labels: subacromial impingement syndrome, rotator cuff tear, bursitis, rotator-cuff-related shoulder pain, shoulder sprain and episode of shoulder pain. PRIMARY AND SECONDARY OUTCOMES: Participants answered two questions (free-text response) about: (1) words or feelings evoked by the label; (2) what treatments they feel are needed. Two researchers iteratively developed coding frameworks to analyse responses.Results1308/1626 (80%) complete responses for each question were analysed. Psychological distress (21%), uncertainty (22%), serious condition (15%) and poor prognosis (9%) were most often expressed by those labelled with subacromial impingement syndrome. For those labelled with a rotator cuff tear, psychological distress (13%), serious condition (9%) and poor prognosis (8%) were relatively common, while minor issue was expressed least often compared with the other labels (5%). Treatment/investigation and surgery were common among those labelled with a rotator cuff tear (11% and 19%, respectively) and subacromial impingement syndrome (9% and 10%) compared with bursitis (7% and 5%). CONCLUSIONS: Words or feelings evoked by certain labels for rotator cuff disease and perceived treatment needs may explain why some labels drive management preferences towards surgery and imaging more than others.

Online Information About the Effectiveness of Shoulder Surgery Is Not Based on the Best Available Evidence: A Content Analysis.

OBJECTIVE: To summarize the proportion of consumer webpages on subacromial decompression and rotator cuff repair surgery that make an accurate portrayal of the evidence for these operations (primary outcome), mention the benefits and harms of surgery, outline alternatives to surgery, and make various surgical recommendations. DESIGN: Content analysis. SETTING: Online consumer information about subacromial decompression and rotator cuff repair surgery. Webpages were identified through (1) Google searches using terms synonymous with "shoulder pain" and "shoulder surgery" and searching "orthopedic surgeon" linked to each Australian capital city and (2) websites of relevant professional associations (eg, Australian Orthopaedic Association). Two reviewers independently identified webpages and extracted data. PARTICIPANTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Whether the webpage made an accurate portrayal of the evidence for subacromial decompression or rotator cuff repair surgery (primary outcome), mentioned benefits and harms of surgery, outlined alternatives to surgery, and made various surgical recommendations (eg, delay surgery). Outcome data were summarized using counts and percentages. RESULTS: A total of 155 webpages were analyzed (n=89 on subacromial decompression, n=90 on rotator cuff repair, n=24 on both). Only 18% (n=16) and 4% (n=4) of webpages made an accurate portrayal of the evidence for subacromial decompression and rotator cuff repair surgery, respectively. For subacromial decompression and rotator cuff repair, respectively, 85% (n=76) and 80% (n=72) of webpages mentioned benefits, 38% (n=34) and 47% (n=42) mentioned harms, 94% (n=84) and 92% (n=83) provided alternatives to surgery, and 63% (n=56) and 62% (n=56) recommended delayed surgery (the most common recommendation). CONCLUSIONS: Most online information about subacromial decompression and rotator cuff repair surgery does not accurately portray the best available evidence for surgery and may be inadequate to inform patient decision making.

Diagnostic Labels for Rotator Cuff Disease Can Increase People's Perceived Need for Shoulder Surgery: An Online Randomized Controlled Trial.

OBJECTIVE: To investigate whether different labels for rotator cuff disease influence people's perceived need for surgery. DESIGN: Randomized controlled experiment. METHODS: Participants with and without shoulder pain read a vignette describing a patient with rotator cuff disease and were randomized to 1 of 6 terms describing rotator cuff disease: subacromial impingement syndrome, rotator cuff tear, bursitis, rotator cuff-related shoulder pain, shoulder sprain, and episode of shoulder pain. Perceived need for shoulder surgery was the primary outcome. Secondary outcomes included perceived need for imaging, an injection, a second opinion, and to see a specialist; perceived seriousness of the condition; recovery expectations; and perceived impact on work attendance. Using a Bonferroni correction (significance, P<.003), adjusted between-group mean differences and 99.67% confidence intervals (CIs) were obtained using a 1-way analysis of covariance. RESULTS: One thousand three hundred eight (80% of 1626) responses were analyzed. Participants' mean ± SD age was 40.3 ± 16.0 years, and 59% were women. Mean perceived need for surgery (0-10 scale) was low and slightly higher among those assigned to the rotator cuff tear label compared to the bursitis label (2.6 versus 2.1; adjusted mean difference, 0.7; 99.67% CI: 0.0, 1.4). Mean perceived need for imaging (0-10) was moderate and slightly higher among those assigned to the rotator cuff tear (4.7 versus 3.7; adjusted mean difference, 1.0; 99.67% CI: 0.2, 1.9) and subacromial impingement syndrome labels (4.7 versus 3.7; adjusted mean difference, 1.0; 99.7% CI: 0.1, 1.9) compared to the bursitis label. CONCLUSION: There were small differences in the perceived need for surgery and imaging between some labels, which could be important at the population level. J Orthop Sports Phys Ther 2021;51(8):401-411. Epub 31 Mar 2021. doi:10.2519/jospt.2021.10375.

Physiotherapy utilisation and costs before lumbar spine surgery: a retrospective analysis of workers compensation claims in Australia.

BACKGROUND: Understanding how much physiotherapy people receive before lumbar spine surgery could give insight into what people and clinicians consider an adequate trial of non-operative management. The aim of this study was to investigate physiotherapy utilisation and costs before lumbar spine surgery under a workers' compensation claim in New South Wales (NSW), Australia. METHODS: Using data from the NSW State Insurance Regulatory Authority, we audited physiotherapy billing codes used before surgery for people who received lumbar spine surgery from 2010 to 2018. We summarised, separately for fusion and decompression, the time from initiation of physiotherapy to surgery, number of physiotherapy sessions people received before surgery, total cost of physiotherapy before surgery, and time from injury date to initiation of physiotherapy. All analyses were descriptive. RESULTS: We included 3070 people (800 had fusion, 2270 decompression). Mean age (standard deviation, SD) was similar between those who received fusion and decompression [42.9 (10.4) vs. 41.9 (11.6)]. Compared to people who had fusion, those who had decompression were more likely to not have any physiotherapy before surgery (28.4% vs. 15.4%), received physiotherapy for a shorter duration before surgery [median (interquartile range, IQR): 5 (3 to 11) vs. 15 (4-26) months], were less likely to have physiotherapy for ≥2 years before surgery (5.6% vs. 27.5%), had fewer physiotherapy sessions before surgery [mean (SD): 16 (21) vs. 28 (35) sessions], were less likely to have > 50 physiotherapy sessions before surgery (6.8% vs. 18.1%), and had lower total physiotherapy-related costs [mean (IQR): $1265 ($0-1808) vs. $2357 ($453-2947)]. Time from injury date to first physiotherapy session was similar between people who had fusion and decompression [median (IQR): 23 (9-66) vs.19 (7-53) days]. CONCLUSIONS: There is variation in physiotherapy utilisation and costs before lumbar spine surgery for people funded by NSW Workers' Compensation. Some people may not be receiving an adequate trial of physiotherapy before surgery, particularly before decompression surgery. Others may be receiving an excessive amount of physiotherapy before surgery, particularly before fusion.

Intensive supervised rehabilitation versus less supervised rehabilitation following anterior cruciate ligament reconstruction? A systematic review and meta-analysis.

OBJECTIVES: To investigate whether intensive supervised rehabilitation following ACL reconstruction leads to superior self-reported function and sports participation compared to less supervised rehabilitation. DESIGN: Systematic review and meta-analysis. METHODS: We included randomised controlled trials (RCTs) comparing supervised rehabilitation to rehabilitation with a similar protocol that used less supervised sessions for athletes following ACL reconstruction. Two reviewers independently screened studies and extracted data. The Physiotherapy Evidence Database (PEDro) scale was used to evaluate methodological quality and GRADE to evaluate overall quality of evidence. Self-reported function and sports participation were the primary outcomes. Data were pooled using random effects meta-analyses. RESULTS: Our search retrieved 4075 articles. Seven articles reporting on six RCTs were included (n=353). Very-low to low-certainty evidence suggests intensive supervised rehabilitation is not superior to less supervised rehabilitation following ACL reconstruction for improving self-reported function, sports participation, knee flexor and extensor strength, range of motion, sagittal plane knee laxity, single leg hop performance, or quality of life. CONCLUSION: Based on uncertain evidence, intensive supervised rehabilitation is not superior to less supervised rehabilitation for athletes following ACL reconstruction. Although high-quality RCTs are needed to provide more certain evidence, clinicians should engage athletes in shared decision making to ensure athletes' rehabilitation decisions align with current evidence on supervised rehabilitation as well as their preferences and values.

Overcoming Overuse Part 5: Is Shared Decision Making Our Excalibur?

SUMMARY: Shared decision making is recommended as a strategy to help patients identify what matters most to them and make informed decisions about musculoskeletal care. In part 5 of the Overcoming Overuse series, we look at the evidence supporting shared decision making as a strategy to help curb overuse. Using shared decision making in clinical consultations may help to reduce the overuse of options that are not beneficial and to increase use of care supported by evidence. Shared decision making could support clinicians in promoting uptake of active rehabilitation options with a favorable balance of benefits to harms. Shared decision making facilitates conversations about unnecessary tests or treatments and could be a key strategy for overcoming overuse. J Orthop Sports Phys Ther 2021;51(2):53-56. doi:10.2519/jospt.2021.0103.

Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis.

OBJECTIVE: To investigate the efficacy and safety of antidepressants for back and osteoarthritis pain compared with placebo. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, International Pharmaceutical Abstracts, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to 15 November and updated on 12 May 2020. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials comparing the efficacy or safety, or both of any antidepressant drug with placebo (active or inert) in participants with low back or neck pain, sciatica, or hip or knee osteoarthritis. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data. Pain and disability were primary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability). A random effects model was used to calculate weighted mean differences and 95% confidence intervals. Safety (any adverse event, serious adverse events, and proportion of participants who withdrew from trials owing to adverse events) was a secondary outcome. Risk of bias was assessed with the Cochrane Collaboration's tool and certainty of evidence with the grading of recommendations assessment, development and evaluation (GRADE) framework. RESULTS: 33 trials (5318 participants) were included. Moderate certainty evidence showed that serotonin-noradrenaline reuptake inhibitors (SNRIs) reduced back pain (mean difference -5.30, 95% confidence interval -7.31 to -3.30) at 3-13 weeks and low certainty evidence that SNRIs reduced osteoarthritis pain (-9.72, -12.75 to -6.69) at 3-13 weeks. Very low certainty evidence showed that SNRIs reduced sciatica at two weeks or less (-18.60, -31.87 to -5.33) but not at 3-13 weeks (-17.50, -42.90 to 7.89). Low to very low certainty evidence showed that tricyclic antidepressants (TCAs) did not reduce sciatica at two weeks or less (-7.55, -18.25 to 3.15) but did at 3-13 weeks (-15.95, -31.52 to -0.39) and 3-12 months (-27.0, -36.11 to -17.89). Moderate certainty evidence showed that SNRIs reduced disability from back pain at 3-13 weeks (-3.55, -5.22 to -1.88) and disability due to osteoarthritis at two weeks or less (-5.10, -7.31 to -2.89), with low certainty evidence at 3-13 weeks (-6.07, -8.13 to -4.02). TCAs and other antidepressants did not reduce pain or disability from back pain. CONCLUSION: Moderate certainty evidence shows that the effect of SNRIs on pain and disability scores is small and not clinically important for back pain, but a clinically important effect cannot be excluded for osteoarthritis. TCAs and SNRIs might be effective for sciatica, but the certainty of evidence ranged from low to very low. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020158521.

Overcoming Overuse Part 4: Small Business Survival.

SUMMARY: The challenge of overuse raises important questions for those in the business of musculoskeletal health care. What is the right number of physical therapy visits for a given condition? Can a practice provide "less" but still be profitable? In this, the editorial on overcoming overuse of musculoskeletal health care, we consider the economic drivers of overuse in the private sector. We propose actions that could support small business leaders to overcome overuse and build profitable, high-quality services. J Orthop Sports Phys Ther 2021;51(1):1-4. doi:10.2519/jospt.2021.0101.