Results From the First Para Report Card on Physical Activity for Children and Adolescents With Disabilities in the Philippines.

A comprehensive evaluation of physical activity (PA) engagement and policy implementation among Filipino children and adolescents with disabilities is vital in the promotion of an active healthy lifestyle. This is the first Para Report Card of the Philippines that presents the available evidence on the 10 commonly used PA indicators. Published and gray literature were searched for country-specific evidence on PA behaviors, physical fitness, and sources of influence. Stakeholders representing relevant national institutions, special education schools, and advocacy groups also provided input on the grades. Only Organized Sport and Government indicators had sufficient data to be graded F and B, respectively. The rest of the indicators were graded as incomplete due to the limited availability of nationally representative data. Findings of the Philippines 2022 Para Report Card on PA highlight the need to strengthen the documentation and evaluation of these indicators among Filipino children and adolescents with disabilities.

Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia.

BACKGROUND: In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence. METHODS: This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis. RESULTS: Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01). CONCLUSION: There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

Selective acceptance of acute whiplash guidelines: a qualitative analysis of perceptions of health professionals in Australia.

PURPOSE: To explore health professionals' acceptance of the guidelines for acute whiplash associated disorders (WAD), and to identify barriers and facilitators to adherence. MATERIALS AND METHODS: Qualitative descriptive study involving focus group discussions among health professionals who treat people with WAD in primary and secondary care settings in New South Wales and Queensland, Australia. Twenty-eight health professionals (physiotherapists = 19; chiropractors = 6; osteopaths = 3) participated in six semi-structured focus group discussions that were held in independent offices in Sydney and Brisbane, Australia between September and December 2015. Discussions were audio recorded and verbatim, de-identified transcripts produced. Thematic analysis was conducted using an inductive approach to identify commonly held beliefs. RESULTS: Acceptance of guideline recommendations appeared to be influenced by factors related to the guideline itself, practitioner and practice characteristics, and patient-related factors. Specifically, acceptance was hindered by conflicting belief systems, ambiguity in guideline recommendations, and patient characteristics and expectations. CONCLUSIONS: Practitioners demonstrated a positive attitude towards the use of the guidelines in general; however, in some cases, acceptance of key recommendations appeared selective. Future guideline revision and implementation might focus on explaining the underlying principles of the guidelines, providing more detailed recommendations, and involving strategies that challenge inconsistent beliefs and promote informed decision-making. IMPLICATIONS FOR REHABILITATIONSelective acceptance of guideline recommendations in favour of those not requiring practice change may present a challenge for the implementation of evidence-based practice in the management of whiplash.Participants demonstrated variable, sometimes polar attitudes to guideline key messages and recommendations.Guideline developers need to focus more strongly on changing practitioner beliefs and attitudes, as well as better explaining the underlying principles of the guidelines, and providing more detailed recommendations.

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.

Impact of an interactive workshop on specialist physiotherapists' practice when implementing a new clinical care pathway for people with musculoskeletal conditions.

BACKGROUND: A new pathway of care proposes early comprehensive assessment and targeted management by specialist musculoskeletal clinicians for people with musculoskeletal conditions at risk of poor outcomes. Adoption of this care pathway is likely to be influenced by beliefs and behaviours of specialist musculoskeletal clinicians. OBJECTIVE: To evaluate the effect of an interactive educational workshop about the proposed clinical care pathway on knowledge, beliefs and practice of specialist musculoskeletal physiotherapists. DESIGN: Mixed methods. METHODS: Fifty specialist musculoskeletal physiotherapists participated in a 2-day interactive educational workshop. Knowledge, beliefs and clinical practice behaviours were assessed immediately before the workshop and 3 months' later using surveys. RESULTS: Knowledge about key guideline messages improved and were maintained at follow-up. Most participants agreed to provide more targeted interventions to patients at risk of poor outcome (92%, 95% CI: 81%-98%) and utilise prognostic screening tools (84%, 95% CI: 71 to 93). However, only 56% (95% CI: 39%-68%) of participants believed implementing a shared care pathway was easy. At follow-up, participants' beliefs were more aligned with the proposed care pathway (i.e., shared care: 83%, 95% CI: 68%-93%). With respect to clinical practice, there were 16% more referrals back to the primary physiotherapist at 3 months than before the workshop. Barriers (practitioner, patient and system factors) to implementation of the care pathway were discussed. CONCLUSION: An interactive educational workshop influenced specialist musculoskeletal physiotherapists' knowledge, beliefs and clinical practice, but barriers need to be overcome to facilitate widespread implementation.

Clinimetric Properties of Self-reported Disability Scales for Whiplash: A Systematic Review for the Whiplash Core Outcome Set (CATWAD).

OBJECTIVES: A core outcomes set (COS) for whiplash-associated disorders (WADs) has been proposed to improve consistency of outcome reporting in clinical trials. Patient-reported disability was one outcome of interest within this COS. The aim of this review was to identify the most suitable tools for measuring self-reported disability in WAD based on clinimetric performance. METHODS: Database searches took place in 2 stages. The first identified outcome measures used to assess self-reported disability in WAD, and the second identified studies assessing the clinimetric properties of these outcome measures in WAD. Data on the study, population and outcome measure characteristics were extracted, along with clinimetric data. Quality and clinimetric performance were assessed in accordance with the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN). RESULTS: Of 19,663 records identified in stage 1 searches, 32 were retained following stage 2 searches and screening. Both the Whiplash Disability Questionnaire and Neck Disability Index performed well in reliability (intraclass correlation coefficient=0.84 to 0.98), construct validity (74% to 82% of hypotheses accepted), and responsiveness (majority of correlations in accordance with hypotheses). Both received Category B recommendations due to a lack of evidence for content validity. DISCUSSION: This review identified the Neck Disability Index and Whiplash Disability Questionnaire as the most appropriate patient-reported outcome measures (PROMs) for assessing self-reported disability in WAD based on moderate to high-quality evidence for sufficient reliability, construct validity and responsiveness. However, the content validity of these PROMs has yet to be established in WAD, and until this is undertaken, it is not possible to recommend 1 PROM over the other for inclusion in the WAD COS.

A randomised controlled trial of implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): Statistical analysis plan.

BACKGROUND: Statistical analysis plans describe the processes of data handling and analysis in clinical trials; by doing so they increase the transparency of the analysis and reporting of studies. This paper reports the planned statistical analysis plan for the Whiplash ImPaCT study. For individuals with whiplash injury, Whiplash ImPaCT aims to assess the effectiveness of a guidelines-based clinical pathway of care compared with usual care. METHODS: We report the planned procedures, methods, and reporting for the primary and secondary analyses of the Whiplash ImPaCT study. The primary outcomes are Global Recovery and Neck Disability Index at 3 months post-randomisation. Outcomes will be analysed according to the intention to treat principle using linear mixed models. A cost-utility analysis will be conducted to compute the incremental cost-effectiveness of the intervention to usual care. We describe data handling, our analytical approach, assumptions about missing data, and our planned methods of reporting. DISCUSSION: This paper will provide a detailed description of the planned analyses for the Whiplash ImPaCT trial.

An Interactive Website for Whiplash Management (My Whiplash Navigator): Process Evaluation of Design and Implementation.

BACKGROUND: Whiplash is a health and economic burden worldwide. Contributing to this burden is poor guideline adherence and variable management by health care professionals (HCPs). Web-based tools that facilitate clinical pathways of care are an innovative solution to improve management. OBJECTIVE: The study aimed to develop, implement, and evaluate a Web-based tool to support whiplash management following a robust process. METHODS: This study followed the first 3 processes of a research translation framework (idea generation, feasibility, and efficacy) to inform the development, implementation, and evaluation of a website that supports HCPs in whiplash management. Development followed the idea generation and feasibility processes to inform the content, design, features, and functionality of the website. This involved stakeholder (eg, industry partners, website developers, and HCPs) consultations through face-to-face meetings, surveys, and focus group discussions. Implementation followed the feasibility process to determine the practicality of the website for clinical use and the most effective strategy to promote wider uptake. Implementation strategies included classroom education, educational meetings, educational outreach, reminders, and direct phone contact. The analysis of website use and practicality of implementation involved collection of website metrics. Evaluation followed the feasibility and efficacy processes to investigate the acceptability and extent to which the website assisted HCPs in gaining knowledge about whiplash management. Surveys were conducted among student, primary, and specialist HCPs to explore ease of access, use, and satisfaction with the website, as well as self-rated improvements in knowledge of risk assessment, management, and communication between HCPs. Website logs of specialist management decisions (eg, shared care, specialist care, and referred care) were also obtained to determine actual practice. RESULTS: The development process delivered an interactive, user-friendly, and acceptable website, My Whiplash Navigator, tailored to the needs of HCPs. A total of 260 registrations were recorded from June 2016 to March 2018, including 175 student, 65 primary, and 20 specialist HCPs. The most effective implementation strategies were classroom education for students (81% uptake, 175/215) and educational meetings for primary HCPs (43% uptake, 47/110). Popular pages visited included advice and exercises and risk assessment. Most HCPs agreed that their knowledge about risk management (79/97, 81%) and exercises (85/97, 88%) improved. The specialists' most common management decision was shared care, an improvement from a previous cohort. Areas to improve were navigation and access to outcome measures. CONCLUSIONS: A robust process resulted in an innovative, interactive, user-friendly, and acceptable website, the My Whiplash Navigator. Implementation with HCPs was best achieved through classroom education and educational meetings. Evaluation of the website showed improved knowledge and practice to be more consistent with a risk-based clinical care pathway for whiplash. The positive results provide sufficient evidence to scale implementation nationally and involve other target markets such as people with whiplash, insurers, and insurance regulators.

Referral to specialist physiotherapists in the management of whiplash associated disorders: Perspectives of healthcare practitioners.

BACKGROUND: Guidelines for whiplash associated disorders (WAD) recommend early referral to specialists (e.g. specialist physiotherapists) of people who are not recovering. This recommendation is a key component of a proposed clinical pathway of care for WAD. OBJECTIVE: To explore healthcare practitioners' opinions about referral to specialist physiotherapists of people with WAD at high risk of non-recovery. DESIGN: Qualitative descriptive study. METHODS: Six focus groups were conducted among primary care allied-health practitioners (n = 16) and specialist physiotherapists (n = 12) in New South Wales and Queensland, Australia. Discussions were audio recorded and transcribed for thematic analysis. RESULTS: Ten themes were generated from analysis. Practitioners appeared to have good knowledge of indicators for referral; however, referrals were often made to the medical practitioner, less commonly to specialist physiotherapists. There was general support for referral to specialist physiotherapists, which was deemed as a viable alternative for people who are not recovering. Practitioners, however, had differing views about the attributes of a specialist physiotherapist and referral timeframe. A number of factors have been identified to influence the referral process and practitioners expressed specific expectations of the desired outcomes of referral as well as considerations for specialist management approaches. There was strong support for a collaborative approach in management that involved the referring practitioner. CONCLUSION: Results support the feasibility of referral to specialist physiotherapists despite limited uptake in practice and recognised barriers to referral. These findings have implications for further study and adopting strategies to facilitate effective implementation and translation of the proposed pathway into primary care practice.

Health practitioners' perceptions of adopting clinical prediction rules in the management of musculoskeletal pain: a qualitative study in Australia.

OBJECTIVES: To investigate health practitioners' understanding and practice behaviours with regards to clinical prediction rules (CPRs) and explore their perceptions of adopting a new whiplash CPR. DESIGN: Qualitative study using six semistructured focus groups. SETTING: Primary and secondary care in New South Wales and Queensland, Australia. PARTICIPANTS: Physiotherapists (n=19), chiropractors (n=6) and osteopaths (n=3) were purposively sampled to include health practitioners who provide routine treatment to people with whiplash-associated disorders. METHODS: Focus group discussions (n=6) were audio-recorded, transcribed verbatim and analysed using an inductive thematic approach. RESULTS: Health practitioners' understanding and use of CPRs were mixed. Clinicians considered components relating to acceptability ('whether I agree with it') and implementation ('how I'll use it') when deciding on whether to adopt a new CPR. Acceptability was informed by four themes: knowledge and understanding, CPR type, congruence and weighted value. Consideration of matters that promote implementation occurred once a CPR was deemed to be acceptable. Three themes were identified as potentially enhancing whiplash CPR implementation: the presence of an external driver of adoption, flexibility in how the CPR could be administered and guidance regarding communication of CPR output to patients. CONCLUSIONS: Education on CPR purpose and fit with practice is needed to enhance the perceived acceptability of CPRs. Strategies that facilitate practitioner motivation, enable administrative flexibility and assist clinicians in communicating the results of the whiplash CPR could promote adoption of the whiplash CPR.

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

INTRODUCTION: Whiplash-associated disorders (WAD) are a huge worldwide health and economic burden. The propensity towards developing into chronic, disabling conditions drives the rise in health and economic costs associated with treatment, productivity loss and compulsory third party insurance claims. Current treatments fail to address the well-documented heterogeneity of WAD and often result in poor outcomes. A novel approach is to evaluate whether the care provided according to the estimated risk of poor prognosis improves health outcomes while remaining cost-effective. RESEARCH QUESTIONS: (1) Does a guideline-based clinical pathway of care improve health outcomes after whiplash injury compared to usual care? (2) Does risk of recovery have a differential effect on health outcomes for the clinical pathway of care? (3) Is the clinical pathway of care intervention cost-effective? (4) What are the variations in professional practice between usual care and the clinical pathway of care? DESIGN: Multi-centre, randomised, controlled trial conducted over two Australian states: Queensland and New South Wales. PARTICIPANTS AND SETTING: 236 people with WAD (grade I-III, within 6 weeks of injury) and their primary healthcare providers. INTERVENTION: A clinical pathway of care, with care matched to the predicted risk of poor recovery. Participants at low risk of ongoing pain and disability (hence, predicted to fully recover) will receive up to three sessions of guideline-based advice and exercise with their primary healthcare provider. Participants at medium/high risk of developing ongoing pain and disability will be referred to a specialist (defined as a practitioner with expertise in whiplash) who will conduct a more in-depth physical and psychological assessment. As a result, the specialist will liaise with the original primary healthcare provider and determine one of three further pathways of care. CONTROL: Usual care provided by the primary healthcare provider that is based on clinical judgment. MEASUREMENTS: Primary (global rating of change and neck-related disability) and secondary (self-efficacy, pain intensity, general health and disability and psychological health) outcomes will be collected using validated scales. Direct (eg, professional care, transportation costs, time spent for care, co-payments) and indirect (eg, lost economic productivity) costs will be obtained through an electronic cost diary. Health and cost outcomes will be assessed at baseline, 3, 6 and 12 months after randomisation. Professional practice outcomes will be evaluated through questionnaires completed by healthcare providers and their patients at 3 months. PROCEDURE: Potential participants (patients) will be identified through emergency departments, primary health clinics and advertisements. Eligible participants will complete baseline assessments and will be categorised into low or medium/high risk of poor recovery using a clinical prediction rule. After this assessment, participants will be randomly allocated to either a control group (n=118) or intervention group (n=118), stratified by risk subgroup and treatment site. The participants' nominated primary healthcare providers will be informed of their involvement in the trial. Consent will be obtained from the primary healthcare providers to participate and to obtain information about professional practice. Participants in the intervention group will additionally have access to an interactive website that provides information about whiplash and recovery relative to their risk category. ANALYSIS: Analysis will be conducted on an intention-to-treat basis. Outcomes will be analysed independently through cross-sectional analyses using generalised linear models methods, with an appropriate link function, to test for an intervention effect, adjusted for the baseline values. The risk category will be tested for its association with treatment effect by adding risk group to the regression equation. Cost-effectiveness will be calculated using utility weights and the resulting measure will be cost per quality-adjusted life year (QALY) saved. Professional practice outcomes will be analysed using descriptive statistics. DISCUSSION: This research is significant as it will be the first study to address the heterogeneity of whiplash by implementing a clinical pathway of care that matches evidence-based interventions to projected risk of poor recovery. The results of this trial have the potential to change clinical practice for WAD, thereby maximising treatment effects, improving patient outcomes, reducing costs and maintaining the compulsory third party system.

Reliability and validity of the Four Square Step Test in children with cerebral palsy and Down syndrome.

Little is known about the measurement properties of clinical tests of stepping in different directions for children with cerebral palsy (CP) and Down syndrome (DS). The ability to step in various directions is an important balance skill for daily life. Standardized testing of this skill can yield important information for therapy planning. This observational methodological study was aimed at defining the relative and absolute reliability, minimal detectable difference, and concurrent validity with the Timed Up-&-Go (TUG) of the Four Square Step Test (FSST) for children with CP and DS. Thirty children, 16 with CP and 14 with DS, underwent repeat testing 2 weeks apart on the FSST by 3 raters. TUG was administered on the second test occasion. Intraclass correlation coefficients (ICC [1,1] and [3,1]) with 95% confidence intervals, standard error of measurement (SEM), minimal detectable difference (MDD) and the Spearman rank correlation coefficient were computed. The FSST demonstrated excellent interrater reliability (ICC=.79; 95% CI: .66, .89) and high positive correlation with the TUG (r=.74). Test-retest reliability estimates varied from moderate to excellent among the 3 raters (.54, .78 and .89 for raters 1, 2 and 3, respectively). SEM and MDD were calculated at 1.91s and 5.29s, respectively. Scores on the FSST of children with CP and DS between 5 and 12 years of age are reliable and valid.

Triclosan-coated sutures reduce the risk of surgical site infections: a systematic review and meta-analysis.

OBJECTIVE To analyze available evidence on the effectiveness of triclosan-coated sutures (TCSs) in reducing the risk of surgical site infection (SSI). DESIGN Systematic review and meta-analysis. METHODS A systematic search of both randomized (RCTs) and nonrandomized (non-RCT) studies was performed on PubMed Medline, OVID, EMBASE, and SCOPUS, without restrictions in language and publication type. Random-effects models were utilized and pooled estimates were reported as the relative risk (RR) ratio with 95% confidence interval (CI). Tests for heterogeneity as well as meta-regression, subgroup, and sensitivity analyses were performed. RESULTS A total of 29 studies (22 RCTs, 7 non-RCTs) were included in the meta-analysis. The overall RR of acquiring an SSI was 0.65 (95% CI: 0.55-0.77; I2=42.4%, P=.01) in favor of TCS use. The pooled RR was particularly lower for the abdominal surgery group (RR: 0.56; 95% CI: 0.41-0.77) and was robust to sensitivity analysis. Meta-regression analysis revealed that study design, in part, may explain heterogeneity (P=.03). The pooled RR subgroup meta-analyses for randomized controlled trials (RCTs) and non-RCTs were 0.74 (95% CI: 0.61-0.89) and 0.53 (95% CI: 0.42-0.66), respectively, both of which favored the use of TCSs. CONCLUSION The random-effects meta-analysis based on RCTs suggests that TCSs reduced the risk of SSI by 26% among patients undergoing surgery. This effect was particularly evident among those who underwent abdominal surgery.