Barriers to reducing preoperative testing for low-risk surgical procedures: A qualitative assessment guided by the Theoretical Domains Framework.

INTRODUCTION: While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. AIM: Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. METHOD: We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. RESULTS: We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years' experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. CONCLUSION: These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.

Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework.

BACKGROUND: Low back pain (LBP) is a leading cause of disability and is among the top five reasons that patients visit their family doctors. Over-imaging for non-specific low back pain remains a problem in primary care. To inform a larger study to develop and evaluate a theory-based intervention to reduce inappropriate imaging, we completed an assessment of the barriers and facilitators to reducing unnecessary imaging for NSLBP among family doctors in Newfoundland and Labrador (NL). METHODS: This was an exploratory, qualitative study describing family doctors' experiences and practices related to diagnostic imaging for non-specific LBP in NL, guided by the Theoretical Domains Framework (TDF). Data were collected using in-depth, semi-structured interviews. Transcripts were analyzed deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) before the results were examined to determine which domains should be targeted to reduce imaging. RESULTS: Nine family doctors (four males; five females) working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings participated in this study. We found five barriers to reducing imaging for patients with NSLBP: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources. These were related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation. CONCLUSIONS: Family physicians a) fear that if they do not image they may miss something serious, b) face significant patient demand for imaging, c) are working in a system that encourages unnecessary imaging, d) don't have enough time to counsel patients about why they don't need imaging, and e) lack access to appropriate practitioners, community programs, and treatment modalities to prescribe to their patients. These barriers were related to seven TDF domains. Successfully reducing inappropriate imaging requires a comprehensive intervention that addresses these barriers using established behaviour change techniques. These techniques should be matched directly to relevant TDF domains. The results of our study represent the important first step of this process - identifying the contextual barriers and the domains to which they are related.

Physical Therapy Management of Low Back Pain: A Survey of Physiotherapists' Current Assessment and Treatment Practices.

Purpose: The purpose of this study was to determine current physiotherapy practice for managing chronic low back pain (LBP). Method: We administered a cross-sectional survey to all physiotherapists working in Eastern Health (EH) Regional Health Authority, Newfoundland and Labrador, by email. To ascertain how physiotherapists assessed and treated patients with LBP, the survey included multiple-choice and open-ended questions, along with case vignettes. We explored the respondents' confidence about implementing all aspects of guideline-based care, as well as their use of treatment outcome measures. Results: A total of 76 physiotherapists responded to the survey (84% response rate); 56 (74%) reported that they treated patients with LBP as part of their regular practice. More than half had managed LBP for more than 10 years. The most frequently used treatments were self-management advice, followed by home and supervised exercise. The majority of respondents lacked confidence about implementing cognitive-behavioural treatment techniques. The Numeric Pain Rating Scale was the most commonly used outcome measure; disability outcome measures were not frequently used. Conclusions: The majority of LBP management in EH aligns with guideline recommendations. Increased uptake of guidelines recommending assessment and management of LBP using a bio-psychosocial approach will require training and support.

Objectif : déterminer les pratiques de physiothérapie actuelles pour traiter les douleurs lombaires chroniques. Méthodologie : les chercheurs ont distribué un sondage transversal par courriel à tous les physiothérapeutes de l'Autorité régionale de la santé de l'Est (SE) de Terre-Neuve-et-Labrador. Pour déterminer la manière dont les physiothérapeutes évaluent et traitent les patients ayant des douleurs lombaires, le sondage incluait des questions à choix multiples, des questions ouvertes et des scénarios de cas. Les chercheurs ont exploré la confiance des répondants envers l'adoption de tous les aspects des soins reposant sur des directives, de même qu'envers les mesures de résultat des traitements. Résultats : au total, 76 physiothérapeutes ont répondu au sondage, pour un taux de réponse de 84 %; 56 (74 %) ont déclaré traiter des patients ayant des douleurs lombaires dans le cadre de leur pratique régulière. Plus de la moitié traitaient des douleurs lombaires depuis plus de dix ans. Les traitements les plus utilisés étaient des conseils d'autogestion, suivis par des exercices à domicile et des exercices supervisés. La majorité des répondants n'avaient pas assez confiance pour adopter des techniques de thérapie cognitivo-comportementale. L'échelle numérique d'évaluation de la douleur était la mesure de résultat la plus utilisée, tandis que les mesures de résultats des incapacités étaient peu utilisées. Conclusion : à la SE, le traitement de la majorité des douleurs lombaires est conforme aux directives. Pour accroître les mises à jour des directives recommandant d'évaluer et de traiter les douleurs lombaires au moyen d'une approche biopsychosociale, il faudra une formation et un soutien.

Patient preferences in tinnitus outcomes and treatments: a qualitative study.

In order to identify patient preferences in care for tinnitus an in depth grounded theory study was conducted. This consisted of interviews with 41 patients who had sought help for tinnitus across a range of locations and tinnitus services in England. Preferences for outcomes were for both the removal of the tinnitus and for improved coping and management of the tinnitus. Preferences for treatment were for individualized care, tailored information and for treatment to assist with psychological adjustment and auditory distraction. Adoption of treatments to manage tinnitus were based on a trial and error approach. Patients? preferences for individual treatments varied but were informed by the information they received. Information plays an important role in care for people with tinnitus. Patients hold individual preferences and require engagement in shared decision making.

IT-based wellness tools for older adults: Design concepts and feedback.

OBJECTIVE: To explore older adults' preferences regarding e-health applications through use of generated concepts that inform wellness tool design. METHODS: The 6-8-5 method and affinity mapping were used to create e-health design ideas that were translated into storyboards and scenarios. Focus groups were conducted to obtain feedback on the prototypes and included participant sketching. A qualitative analysis of the focus groups for emerging themes was conducted, and sketches were analyzed. RESULTS: Forty-three older adults participated in six focus group sessions. The majority of participants found the wellness tools useful. Preferences included features that supported participants in areas of unmet needs, such as ability to find reliable health information, cognitive training, or maintaining social ties. Participants favored features such as use of voice navigation, but were concerned over cost and the need for technology skills and access. Sketches reinforced these wants, including portability, convenience, and simplicity. CONCLUSIONS: Several factors were found to increase the desirability of such devices including convenient access to their health and health information, a simple, accessible interface, and support for memory issues. Researchers and designers should incorporate the feedback of older adults regarding wellness tools, so that future designs meet the needs of older adults.

Systematic Review of Costs and Effects of Self-Management Interventions for Chronic Musculoskeletal Pain: Spotlight on Analytic Perspective and Outcomes Assessment.

Background: Evidence for the cost-effectiveness of self-management interventions for chronic musculoskeletal pain (CMP) lacks consensus, which may be due to variability in the costing methods employed. Purpose: The purposes of the study were to identify how costs and effects have been assessed in economic analysis of self-management interventions for CMP and to identify the effect of the chosen analytical perspective on cost-effectiveness conclusions. Data Sources: Five databases were searched for all study designs using relevant terms. Study Selection: Two independent researchers reviewed all titles for predefined inclusion criteria: adults (≥18 years of age) with CMP, interventions with a primary aim of promoting self-management, and conducted a cost analysis. Data Extraction: Descriptive data including population, self-management intervention, analytical perspective, and costs and effects measured were collected by one reviewer and checked for accuracy by a second reviewer. Data Synthesis: Fifty-seven studies were identified: 65% (n = 37) chose the societal perspective, of which 89% (n = 33) captured health care utilization, 92% (n = 34) reported labor productivity, 65% (n = 24) included intervention delivery, and 59% (n = 22) captured patient/family costs. Types of costs varied in all studies. Eight studies conducted analyses from both health service and societal perspectives; cost-effectiveness estimates varied with perspective chosen, but in no case was the difference sufficient to change overall policy recommendations. Limitations: Chronic musculoskeletal pain conditions where self-management is recommended, but not as a primary treatment, were excluded. Gray literature was excluded. Conclusion: Substantial heterogeneity in the cost components captured in the assessment of self-management for CMP was found; this was independent of the analytic perspective used. Greater efforts to ensure complete and consistent costings are required if reliable cost-effectiveness evidence of self-management interventions is to be generated and to inform the most appropriate perspective for economic analyses in this field.

Examining Korean and Korean American older adults' perceived acceptability of home-based monitoring technologies in the context of culture.

OBJECTIVE: Despite the increasing use of home-based monitoring technologies by older adults, few studies have examined older adults' acceptance of these technologies, especially among people from diverse cultural groups. The purpose of this study was to explore Korean and Korean American older adults' attitudes toward and perceptions of home-based monitoring technologies in a cultural context. METHODS: A qualitative analysis of focus groups and individual interviews using inductive coding methods and a constant comparative approach for emerging themes was conducted. RESULTS: Several cultural factors that determine the acceptability of home-based monitoring technologies were identified. Most notably, the necessity of living alone due to loosened filial tradition and immigration was a main motivator for adopting these technologies for both Korean and Korean Americans. The level of satisfaction with the health care system or therapeutic interaction affected participants' perceived need for technologies. Compared with the Korean American group, Korean older adults regarded the government's role as more important in increasing adoption and use of new technologies. CONCLUSIONS: Contextual factors need to be considered when explaining perceptions of home-based monitoring technologies among older adults from various ethnic groups and developing diffusion strategies according to end users' attitudes, experiences, and cultural backgrounds.

Tools developed and disseminated by guideline producers to promote the uptake of their guidelines.

BACKGROUND: The uptake of clinical practice guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage faster adoption of new guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs. OBJECTIVES: To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective. SEARCH METHODS: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own guidelines. The guideline could target any clinical area. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane 'Risk of bias' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to guidelines. MAIN RESULTS: We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.Two of the four included studies reported data on healthcare professionals' adherence to guidelines. A guideline tool developed by the producers of a guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service. AUTHORS' CONCLUSIONS: Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.

Using mixed methods evaluation to assess the feasibility of online clinical training in evidence based interventions: a case study of cognitive behavioural treatment for low back pain.

BACKGROUND: Cognitive behavioural (CB) approaches are effective in the management of non-specific low back pain (LBP). We developed the CB Back Skills Training programme (BeST) and previously provided evidence of clinical and cost effectiveness in a large pragmatic trial. However, practice change is challenged by a lack of treatment guidance and training for clinicians. We aimed to explore the feasibility and acceptability of an online programme (iBeST) for providing training in a CB approach. METHODS: This mixed methods study comprised an individually randomised controlled trial of 35 physiotherapists and an interview study of 8 physiotherapists. Participants were recruited from 8 National Health Service departments in England and allocated by a computer generated randomisation list to receive iBeST (n = 16) or a face-to-face workshop (n = 19). Knowledge (of a CB approach), clinical skills (unblinded assessment of CB skills in practice), self-efficacy (reported confidence in using new skills), attitudes (towards LBP management), and satisfaction were assessed after training. Engagement with iBeST was assessed with user analytics. Interviews explored acceptability and experiences with iBeST. Data sets were analysed independently and jointly interpreted. RESULTS: Fifteen (94 %) participants in the iBeST group and 16 (84 %) participants in the workshop group provided data immediately after training. We observed similar scores on knowledge (MD (95 % CI): 0.97 (-1.33, 3.26)), and self-efficacy to deliver the majority of the programme (MD (95 % CI) 0.25 (-1.7; 0.7)). However, the workshop group showed greater reduction in biomedical attitudes to LBP management (MD (95 % CI): -7.43 (-10.97, -3.89)). Clinical skills were assessed in 5 (33 %) iBeST participants and 7 (38 %) workshop participants within 6 months of training and were similar between groups (MD (95 % CI): 0.17(-0.2; 0.54)). Interviews highlighted that while initially sceptical, participants found iBeST acceptable. A number of strategies were identified to enhance future versions of iBeST such as including more skills practice. CONCLUSIONS: Combined quantitative and qualitative data indicated that online training was an acceptable and promising method for providing training in an evidence based complex intervention. With future enhancement, the potential reach of this training method may facilitate evidence-based practice through large scale upskilling of the workforce. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82203145 (registered prospectively on 03.09.2012).

Cardiovascular Risk Assessment and Management in Prerenal Transplantation Candidates.

Cardiovascular (CV) assessment in prerenal transplant patients varies by center. Current guidelines recommend stress testing for candidates if ≥ 3 CV risk factors exist. We evaluated the CV assessment and management in 685 patients referred for kidney transplant over a 7-year period. All patients had CV risk factors, and the most common cause of end-stage renal disease was diabetes. Thirty-three percent (n = 229) underwent coronary angiography. The sensitivity of stress testing to detect obstructive coronary artery disease (CAD) was poor (0.26). Patients who had no CAD, nonobstructive CAD, or CAD with intervention had significantly higher event-free survival compared with patients with obstructive CAD without intervention. There were no adverse clinical events (death, myocardial infarction, stroke, revascularization, and graft failure) within 30 days post-transplant in patients who had preoperative angiography (n = 77). Of the transplanted patients who did not have an angiogram (n = 289), there were 8 clinical events (6 myocardial infarctions) in the first 30 days. In conclusion, our results indicate that stress testing and usual risk factors were poor predictors of obstructive CAD and that revascularization may prove beneficial in these patients.

How to Design Tobacco Prevention and Control Games for Youth and Adolescents: A Qualitative Analysis of Expert Interviews.

OBJECTIVE: Games for health, including digital videogames and gaming-based approaches, are increasingly being used in health promotion research and practice. Recently published research has shown that videogames have significant potential to promote healthy behaviors among youth and adolescents. Yet, there is a lack of available evidence-based resources to guide practitioners on the integration of games into tobacco prevention and smoking cessation interventions. To address this gap, expert researchers and game developers were interviewed to further define games for health, explore the current research, and provide recommendations for developing, evaluating, and promoting effective anti-tobacco games. MATERIALS AND METHODS: Nationally recognized experts on game development, games for health, tobacco, and health behavior were asked to participate. A qualitative analysis of 25 in-depth individual interviews using a constant comparative approach for emerging themes was conducted. RESULTS: Main themes that emerged from the data analysis included the following: (1) the current state of games for health research to facilitate health behavior change, (2) strategies for how to develop and evaluate games for quality and impact, and (3) recommendations for how to effectively design tobacco prevention and smoking cessation educational videogames that engage youth and adolescents. CONCLUSIONS: The synthesized findings identified through these expert interviews offer stakeholders strategies for how to incorporate games for health within their current and future work. Specific recommendations are presented for developers and researchers to consider when developing and evaluating videogames for tobacco prevention and smoking cessation targeted at youth and adolescents.

The role of volunteer support in the community for adults with hearing loss and hearing aids.

OBJECTIVES: To explore interactions between audiology patients and volunteers, to describe encounters and define the role of volunteers. METHODS: Qualitative ethnographic and interview study of volunteer-patient interactions. Ten volunteer participants from two volunteer schemes in South West England were observed and interviewed. Three patient participants were interviewed. RESULTS: Analysis of observational data showed that volunteers provided support relating to local services and hearing aids, but did not engage in discussions about hearing loss. Interviews with volunteers identified gaps in audiology provision, including accessible services and clear information and highlighted a need for more support from audiology services to enable them to fulfil their role. Volunteer interactions with patients mimicked a clinician-patient encounter and volunteers employed strategies and behaviours used by professional audiologists. CONCLUSIONS: Audiology volunteers could provide an accessible bridge between health services and the community but their care is limited to focus on hearing aids. PRACTICE IMPLICATIONS: Volunteers enable patients to use hearing aids appropriately and are a core element of current care arrangements. However, volunteers express a need for adequate support from audiology services. Volunteers have the potential to increase service capacity and to bridge the gaps between community and audiology healthcare services.

The digital health divide: evaluating online health information access and use among older adults.

OBJECTIVE: Innovations in health information technology (HIT) provide opportunities to reduce health care spending, improve quality of care, and improve health outcomes for older adults. However, concerns relating to older adults' limited access and use of HIT, including use of the Internet for health information, fuel the digital health divide debate. This study evaluated the potential digital health divide in relation to characteristic and belief differences between older adult users and nonusers of online health information sources. METHODS: A cross-sectional survey design was conducted using a random sample of older adults. A total of 225 older adults (age range = 50-92 years, M = 68.9 years, SD = 10.4) participated in the study. RESULTS: Seventy-six percent of all respondents had Internet access. Users and nonusers of online health information differed significantly on age (M = 66.29 vs. M = 71.13), education, and previous experience with the health care system. Users and nonusers of online health information also differed significantly on Internet and technology access, however, a large percentage of nonusers had Internet access (56.3%), desktop computers (55.9%), and laptop computers or netbooks (43.2%). Users of online health information had higher mean scores on the Computer Self-Efficacy Measure than nonusers, t(159) = -7.29, p < .0001. CONCLUSION: This study found significant differences between older adult users and nonusers of online health information. Findings suggest strategies for reducing this divide and implications for health education programs to promote HIT use among older adults.

Identifying the science and technology dimensions of emerging public policy issues through horizon scanning.

Public policy requires public support, which in turn implies a need to enable the public not just to understand policy but also to be engaged in its development. Where complex science and technology issues are involved in policy making, this takes time, so it is important to identify emerging issues of this type and prepare engagement plans. In our horizon scanning exercise, we used a modified Delphi technique. A wide group of people with interests in the science and policy interface (drawn from policy makers, policy adviser, practitioners, the private sector and academics) elicited a long list of emergent policy issues in which science and technology would feature strongly and which would also necessitate public engagement as policies are developed. This was then refined to a short list of top priorities for policy makers. Thirty issues were identified within broad areas of business and technology; energy and environment; government, politics and education; health, healthcare, population and aging; information, communication, infrastructure and transport; and public safety and national security.

Heart failure patients' perceptions and use of technology to manage disease symptoms.

BACKGROUND: Technology use for symptom management is beneficial for both patients and physicians. Widespread acceptance of technology use in healthcare fuels continued development of technology with ever-increasing sophistication. Although acceptance of technology use in healthcare by medical professionals is evident, less is known about the perceptions, preferences, and use of technology by heart failure (HF) patients. This study explores patients' perceptions and current use of technology for managing HF symptoms (MHFS). MATERIALS AND METHODS: A qualitative analysis of in-depth individual interviews using a constant comparative approach for emerging themes was conducted. Fifteen participants (mean age, 64.43 years) with HF were recruited from hospitals, cardiology clinics, and community groups. RESULTS: All study participants reported use of a home monitoring device, such as an ambulatory blood pressure device or bathroom scale. The majority of participants reported not accessing online resources for additional MHFS information. However, several participants stated their belief that technology would be useful for MHFS. Participants reported increased access to care, earlier indication of a worsening condition, increased knowledge, and greater convenience as potential benefits of technology use while managing HF symptoms. For most participants financial cost, access issues, satisfaction with current self-care routine, mistrust of technology, and reliance on routine management by their current healthcare provider precluded their use of technology for MHFS. CONCLUSIONS: Knowledge about HF patients' perceptions of technology use for self-care and better understanding of issues associated with technology access can aid in the development of effective health behavior interventions for individuals who are MHFS and may result in increased compliance, better outcomes, and lower healthcare costs.

Assessment of the therapeutic alliance in physical rehabilitation: a RASCH analysis.

PURPOSE: To investigate the psychometric properties of the Working Alliance Inventory Theory of Change Inventory (WATOCI) in physical rehabilitation. METHODS: RASCH analysis was used to examine the validity, internal consistency, reliability and discriminative properties of the 16-item WATOCI. Data was obtained from a randomized controlled trial, which employed the WATOCI to measure the alliance between physical therapists and patients with chronic low back pain. RESULTS: The results indicated that 7 items on the 16-item WATOCI should need to be improved for use in physiotherapy settings. The resulting 9-item version of the WATOCI was found to be a uni-dimensional tool for measuring alliance, however, demonstrated a ceiling effect. CONCLUSIONS: There are several items in the WATOCI that require re-wording and/or re-contextualization prior to its use in clinical practice. Specifically, items relating more to the element social interaction did not discriminate well in this population and one solution may be to provide a therapy-specific context. Items regarding how well the patient understood the purpose of the treatment discriminated best between patients and this area is recommended for further development in the tool's assessment. It is recommended that future research address these issues prior to its use in clinical settings.

Tai chi exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial.

OBJECTIVE: To determine the effect of tai chi exercise on persistent low back pain. METHODS: We performed a randomized controlled trial in a general community setting in Sydney, New South Wales, Australia. Participants consisted of 160 volunteers between ages 18 and 70 years with persistent nonspecific low back pain. The tai chi group (n = 80) consisted of 18 40-minute sessions over a 10-week period delivered in a group format by a qualified instructor. The waitlist control group continued with their usual health care. Bothersomeness of back symptoms was the primary outcome. Secondary outcomes included pain intensity and pain-related disability. Data were collected at pre- and postintervention and analyzed by intent-to-treat. RESULTS: Tai chi exercise reduced bothersomeness of back symptoms by 1.7 points on a 0-10 scale, reduced pain intensity by 1.3 points on a 0-10 scale, and improved self-report disability by 2.6 points on the 0-24 Roland-Morris Disability Questionnaire scale. The followup rate was >90% for all outcomes. These results were considered a worthwhile treatment effect by researchers and participants. CONCLUSION: This is the first pragmatic randomized controlled trial of tai chi exercise for people with low back pain. It showed that a 10-week tai chi program improved pain and disability outcomes and can be considered a safe and effective intervention for those experiencing long-term low back pain symptoms.

A randomized controlled trial of tai chi for long-term low back pain (TAI CHI): study rationale, design, and methods.

BACKGROUND: Low back pain persisting for longer than 3 months is a common and costly condition for which many current treatments have low-moderate success rates at best. Exercise is among the more successful treatments for this condition, however, the type and dosage of exercise that elicits the best results is not clearly defined. Tai chi is a gentle form of low intensity exercise that uses controlled movements in combination with relaxation techniques and is currently used as a safe form of exercise for people suffering from other chronic pain conditions such as arthritis. To date, there has been no scientific evaluation of tai chi as an intervention for people with back pain. Thus the aim of this study will be to examine the effects of a tai chi exercise program on pain and disability in people with long-term low back pain. METHODS AND DESIGN: The study will recruit 160 healthy individuals from the community setting to be randomised to either a tai chi intervention group or a wait-list control group. Individuals in the tai chi group will attend 2 tai chi sessions (40 minutes)/week for 8 weeks followed by 1 tai chi session/week for 2 weeks. The wait-list control will continue their usual health care practices and have the opportunity to participate in the tai chi program once they have completed the follow-up assessments. The primary outcome will be bothersomeness of back symptoms measured with a 0-10 numerical rating scale. Secondary outcomes include, self-reports of pain-related disability, health-related quality of life and global perceived effect of treatment. Statistical analysis of primary and secondary outcomes will be based on the intention to treat principle. Linear mixed models will be used to test for the effect of treatment on outcome at 10 weeks follow up. This trial has received ethics approval from The University of Sydney Human Research Ethics Committee. HREC Approval No.10452 DISCUSSION: This study will be the first trial in this area and the information on its effectiveness will allow patients, clinicians and treatment funders to make informed choices regarding this treatment. TRIAL REGISTRATION: This trial has been registered with Australian New Zealand Clinical Trials Registry. ACTRN12608000270314.

Effective e-learning for health professionals and students--barriers and their solutions. A systematic review of the literature--findings from the HeXL project.

INTRODUCTION: In 2003/4 the Information Management Research Institute, Northumbria University, conducted a research project to identify the barriers to e-learning for health professionals and students. The project also established possible ways to overcome these barriers. The North of England Workforce Development Confederation funded the project. METHODOLOGY: The project comprised a systematic review of the literature on barriers to and solutions/critical success factors for e-learning in the health field. Fifty-seven references were suitable for analysis. This review was supplemented by a questionnaire survey of learners and an interview study of learning providers to ensure that data identified from the literature were grounded in reality. RESULTS: The main barriers are: requirement for change; costs; poorly designed packages; inadequate technology; lack of skills; need for a component of face-to-face teaching; time intensive nature of e-learning; computer anxiety. A range of solutions can solve these barriers. The main solutions are: standardization; strategies; funding; integration of e-learning into the curriculum; blended teaching; user friendly packages; access to technology; skills training; support; employers paying e-learning costs; dedicated work time for e-learning. CONCLUSIONS: The authors argue that librarians can play an important role in e-learning: providing support and support materials; teaching information skills; managing and providing access to online information resources; producing their own e-learning packages; assisting in the development of other packages.