Evaluation of the vestibular/ocular motor screening assessment in active combat sport athletes: an exploratory study.

OBJECTIVE: The first aim of this study was to compare the results of the vestibular/ocular motor screening (VOMS) in combat sport athletes with a healthy control population. Second, to explore differences between athletes with and without a concussion history. Third, to examine the relationship between VOMS and the Post-Concussion Symptom Scale (PCSS) in combat sport athletes. PARTICIPANTS: Forty active male combat sport athletes and 40 healthy male control participants were recruited from 4 clubs and a University in Australia. METHODS: Participants completed the VOMS in a primary care physiotherapy clinic. Participants completed an injury questionnaire and the PCSS. RESULTS: An "abnormal" score in at least one subtest or near point convergence (NPC) was recorded in 45% of the combat group compared with 22.5% of the control group. All VOMS scores and NPC distance were greater in the combat group compared with control group (p < 0.05). The VOMS scores were found to be moderately positively correlated with the PCSS. There was no difference in VOMS between athletes with and without a history of concussion (p > 0.05). CONCLUSION: VOMS scores differed between combat sport athletes and control participants. The PCSS may aid clinicians in identifying athletes who have underlying vestibular/oculomotor impairment.

Physiotherapists Both Reproduce and Resist Biomedical Dominance when Working With People With Low Back Pain: A Qualitative Study Towards New Praxis.

Despite recommendations to incorporate physical and psychosocial factors when providing care for people with back pain, research suggests that physiotherapists continue to focus on biological aspects. This study investigated how interpersonal and institutional norms influence this continued enactment of the biological aspects of management. We used theoretically-driven analysis, drawing from Foucauldian notions of power, to analyse 28 ethnographic observations of consultations and seven group discussions with physiotherapists. Analysis suggested that physiotherapy training established expectations of what a physiotherapist 'should' focus on, and institutional circumstances strongly drew the attention of physiotherapists towards biological aspects. Resistance to these forces was possible when, for example, physiotherapists reflected upon their practice, used silences and pauses during consultations, and actively collaborated with patients. These circumstances facilitated use of non-biomedical management approaches. Findings may assist physiotherapists to rework the enduring normative focus on biomedical aspects of care when providing care for patients with back pain.

Shoulder internal and external rotation strength and prediction of subsequent injury in water-polo players.

Water-polo players have greater isokinetic shoulder strength than age-matched controls. Due to the repetitive demands of throwing, however, water-polo players demonstrate an altered strength ratio, with greater internal rotation (IR) strength relative to external rotation (ER). The relationship between shoulder strength and risk of shoulder injury is unknown. In addition, the effect on test position for strength testing on the reliability of handheld dynamometry (HHD) in this population is not known. The aims were to determine the: (a) Inter-rater reliability of HHD testing of IR and ER strength in two positions: neutral and 90°abduction-90°ER (90-90) and (b) relationship between preseason shoulder strength and occurrence of future injury in sub-elite water-polo players. Two assessors measured shoulder IR and ER strength using HHD in 15 water-polo players across two testing days. Athletes were followed over a 6-month period, and injury was assessed and recorded by the team physiotherapist. Measurement of water-polo players' isometric IR and ER strength in the clinical setting had good to excellent inter-rater reliability; however, systematic error was observed in the neutral position but not the 90-90 position. Irrespective of testing position, the neutral and 90-90 test position showed a significant difference (P = 0.01) in absolute preseason IR and ER mean strength between prospectively injured and non-injured players. There was no significant difference in strength ratio or strength normalized for body mass index. These results suggest that preseason strength testing may help identify players at risk of in-season shoulder injury.

Throwing performance in water polo is related to in-water shoulder proprioception.

Water polo players require a high level of upper-extremity strength, flexibility and coordination to achieve a peak level of throwing performance. Increased levels of shoulder proprioceptive acuity, strength and range of motion (ROM) have been previously associated with higher sporting performance. A coach-rating scale, used to quantify an athlete's kicking proficiency in soccer; was adapted in the current study to measure each coach's subjective expert opinion regarding athletes' throwing mechanics, velocity, and accuracy. To examine this hypothesis shoulder proprioception acuity of 18 water polo players was measured both in-water and on-land using an AMEDA apparatus and correlated with coach-rated throwing performance and clinical measures of shoulder strength and ROM. There was a moderate positive correlation between the in-water and the on-land proprioception acuity (r = 0.47, p < 0.05). The in-water score showing a strong positive correlation with coach rated throwing mechanics (r = 0.68, p < 0.05) and velocity (r = 0.75, p = 0.02), suggesting that superior proprioception acuity contributed to fast, mechanically-efficient throwing. These findings support the notion that in-water proprioceptive acuity is an important determinant of the throwing performance achieved by water polo athletes and its measurement may be a valuable adjunct to current athlete screening.

Cervical spine kinematics during machine-based and live scrummaging.

The aim of this study was to compare cervical spine kinematics in rugby union front row players during machine-based and "live" scrummaging. Cervical spine kinematics was measured via electromagnetic tracking of sensors attached to the head and thorax. Joint angles were extracted from each trial at two time points ("bind" prior to engagement and instant of impact) for comparison between scrummaging conditions. The effect of scrummaging condition on kinematics was evaluated using a mixed effects model and estimations were based on a Bayesian framework. With differences ranging from 38° to 50°, the results show that the cervical spine is consistently more flexed when scrummaging against opponents than against a scrum machine. In contrast, there are little differences in the excursion of lateral-flexion (range 5-8°) and axial rotation (7°) between the two conditions. The findings from this study provide clear information on motion patterns in different scrum formations, and suggest that the current design of scrum machines may not promote the same pattern of movement that occurs in live scrums. The results highlight that findings from previous studies that have investigated kinematics during machine-based scrummaging may not be generalisable to a competitive scrummaging context.

Reliability of 2 protocols for assessing pressure pain threshold in healthy young adults.

OBJECTIVE: The purposes of this study were to determine whether there were differences in mean values or reliability for 2 frequently used protocols for pressure pain threshold (PPT) and to calculate how large a difference in PPT is necessary to be 95% confident that a real change has occurred. METHODS: Thirteen participants (8 females) aged 22.3 (±2.3) years from a university community were included. Two testers evaluated participants using 2 protocols, in which PPT was measured 3 times at 8 different body locations. The "cluster protocol" consisted of 3 successive measurements at each location with a 30-second rest between each measurement. The "circuit protocol" consisted of 1 measurement taken at each anatomical location until "the circuit" was complete and then repeated a total of 3 times. RESULTS: A 2-way analysis of variance did not reveal significant differences between protocols at any body location (P = .46-.98). Intertester reliability was good to excellent for all locations (intraclass correlation coefficient, 0.84-0.96), and limits of agreement ranged from 108 to 223 kPa. CONCLUSIONS: Either the cluster or circuit protocol can be used to measure PPT in clinical or research setting. A difference of 160 kPa is considered sufficient to indicate a real difference between repeated measures of PPT regardless of protocol used for testing.

Swing kinematics of male and female skilled golfers following prolonged putting practice.

Given that males and females respond differently to endurance-based tasks, prolonged putting practice may provide an avenue to examine gender-related differences in golf swing kinematics. The aim of this project was to determine if 40 min of putting affects thorax and pelvis kinematics during the full swing of males and females. Three-dimensional trunk kinematics were collected during the swings of 19 male (age: 26 ± 7 years, handicap: 0.6 ± 1.1) and 17 female (age: 24 ± 7 years, handicap: 1.4 ± 1.7) golfers before and after 40 min of putting. Angular displacement at address, top of backswing and ball contact for the pelvis, thorax, and pelvis-thorax interaction were calculated, in addition to the magnitude of peak angular velocity and repeatability of continuous segment angular velocities. Female golfers had less pelvis and thorax anterior-posterior tilt at address, less thorax and thorax-pelvis axial rotation at top of backswing, and less pelvis and thorax axial rotation and pelvis lateral tilt at ball contact pre- to post-putting. Analysis of peak angular velocities revealed that females had significantly lower thorax-pelvis lateral tilt velocity pre- to post-putting. In conclusion, an endurance-based putting intervention affects females' thorax and pelvis orientation angles and velocities to a greater extent than males.

Efficacy of Conservative Interventions for Musculoskeletal Conditions on Pain and Disability in Active Serving Military Personnel-A Systematic Review.

INTRODUCTION: Musculoskeletal (MSK) injuries and associated pain disorders are one of the leading causes for soldiers not being medically fit for deployment, impacting force capability and readiness. Musculoskeletal pain continues to be a leading cause of disability within military services and is associated with a substantial financial burden. A better understanding of the effectiveness of MSK pain management strategies is required. This review was designed to determine the efficacy of nonsurgical interventions, such as physiotherapy, exercise, pharmacology, and multidisciplinary programs, to manage MSK conditions in active serving military populations. MATERIALS AND METHODS: MEDLINE, Embase, CINAHL, and SPORTDiscus were searched to identify relevant randomized clinical trials. Recommended methods were used for article identification, selection, and data extraction. The Cochrane Risk of Bias tool and the Grade of Recommendation, Assessment, Development, and Evaluation were used to appraise the studies. Where possible, meta-analyses were performed. The review was conducted according to the PRISMA guidelines. RESULTS: Nineteen articles (1,408 participants) met the eligibility criteria. Low back pain (LBP) was the most frequently investigated condition, followed by knee pain, neck pain, and shoulder pain. Early physiotherapy, exercise and adjunct chiropractic manipulation (for LBP), and multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology) (for chronic MSK pain) improved pain (standardized mean difference ranged from -0.39 to -1.34; low strength of evidence). Participation in multidisciplinary pain programs, adjunct chiropractic manipulation, and early physiotherapy improved disability (for LBP) (standardized mean difference ranged from -0.45 to -0.86; low to very low strength of evidence). No studies evaluated pain medication. Dietary supplements (glucosamine, chondroitin sulfate, and manganese ascorbate), electrotherapy, isolated lumbar muscle exercises, home cervical traction, or training in virtual reality showed no benefit. The studies had a high risk of bias, were typically underpowered, and demonstrated high clinical heterogeneity. CONCLUSIONS: Currently available randomized clinical trials do not provide sufficient evidence to guide military organizations or health care professionals in making appropriate treatment decisions to manage MSK pain in active serving military personnel. Future research is essential to enable evidence-based recommendations for the effective management of MSK pain conditions in this unique population.

Fostering equitable change in health services: Using critical reflexivity to challenge dominant discourses in low back pain care in Australia.

OBJECTIVES: Justice and equity-focused practices in health services play a critical but overlooked role in low back pain (LBP) care. Critical reflexivity - the ability to examine and challenge power relations, and broader social issues embedded in everyday life - can be a useful tool to foster practices that are more socially just. No research has yet explored this approach in back pain health services. This study sought to understand how clinicians construct LBP in relation to broader socio-cultural-political aspects of care and explore if those constructions changed when clinicians engaged with critically reflexive dialogues with researchers. METHODS: Using critical discourse analysis methods, this qualitative study explored institutionalised patterns of knowledge in the construction of LBP care. We conducted 22 critically reflexive dialogues with 29 clinicians from two health services in Australia - a private physiotherapy clinic and a public multidisciplinary pain clinic. RESULTS: Our analyses suggested that clinicians and services often constructed LBP care at an individual level. This dominant individualistic discourse constrained consideration of justice-oriented practices in the care of people with LBP. Through dialogues, discursive constructions of LBP care expanded to incorporate systems and health service workplace practices. This expansion fostered more equitable clinical and service practices - such as assisting patients to navigate health care systems, considering patients' socioeconomic circumstances when developing treatment plans, encouraging staff discussion of possible systemic changes to enhance justice, and fostering a more inclusive workplace culture. Although such expansions faced challenges, incorporating broader discourses enabled recommendations to address LBP care inequities. CONCLUSIONS: Critical reflexivity can be a tool to foster greater social justice within health services. By expanding constructions of LBP care beyond individuals, critical reflexive dialogues can foster discussion and actions towards more equitable workplace cultures, services and systems.

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic.

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

Patients report being satisfied with private musculoskeletal physical therapy when therapists educate effectively and facilitate shared decision making.

BACKGROUND: Overall satisfaction with physical therapy care can improve patient adherence and active involvement in their management. However, which individual factors most influence satisfaction with private practice physical therapy care is not well established. OBJECTIVE: To identify which aspects of the private practice musculoskeletal physical therapy experience best delineated "completely satisfied" and "dissatisfied patients". METHODS: The MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) was used in a cross-sectional design within 18 Australian private musculoskeletal physical therapy practices. The area under the curve (AUC) of receiver operator characteristic curves (ROC) was used to quantify the ability of the individual patient experience questions to classify the global impressions of satisfaction and likelihood to recommend to others. RESULTS: 1712 patients completed the survey (out of 7320 survey recipients - response rate 23%). High scores were identified for overall satisfaction (4.8/5 ± 0.61) and likelihood to recommend (4.78/5 ± 0.67). Individual items relating to education (AUC = 0.839 and 0.838) and shared decision making (AUC = 0.832 and 0.811) were the most accurate indicators of satisfaction and likelihood to recommend to others, respectively. CONCLUSION: Individual questionnaire items relating to education and shared decision making were the most accurate indicators of satisfaction and likelihood to recommend in patients attending private practice musculoskeletal physical therapy in Australia. Clinicians and educators should focus on developing these skills to encourage an effective therapeutic alliance and promote greater levels of patient satisfaction.

Repeatability of three-dimensional thorax and pelvis kinematics in the golf swing measured using a field-based motion capture system.

Field-based methods of evaluating three-dimensional (3D) swing kinematics offer coaches and researchers the opportunity to assess golfers in context-specific environments. The purpose of this study was to establish the inter-trial, between-tester, between-location, and between-day repeatability of thorax and pelvis kinematics during the downswing using an electromagnetic motion capture system. Two experienced testers measured swing kinematics in 20 golfers (handicap < or =14 strokes) on consecutive days in an indoor and outdoor location. Participants performed five swings with each of two clubs (five-iron and driver) at each test condition. Repeatability of 3D kinematic data was evaluated by computing the coefficient of multiple determination (CMD) and the systematic error (SE). With the exception of pelvis forward bend for between-day and between-tester conditions, CMDs exceeded 0.854 for all variables, indicating high levels of overall waveform repeatability across conditions. When repeatability was compared across conditions using MANOVA, the lowest CMDs and highest SEs were found for the between-tester and between-day conditions. The highest CMDs were for the inter-trial and between-location conditions. The absence of significant differences in CMDs between these two conditions supports this method of analysing pelvis and thorax kinematics in different environmental settings without unduly affecting repeatability.

Investigating the effects of mobilization with movement and exercise on pain modulation processes in shoulder pain - a single cohort pilot study with short-term follow up.

OBJECTIVE: To explore the association between manual therapy and exercise and pain modulation and clinical characteristics in people with musculoskeletal shoulder pain. METHODS: This is a prospective, longitudinal, single cohort pilot study. People with shoulder pain for longer than 6 weeks underwent 4 weeks of glenohumeral mobilization with movement and shoulder exercises. Measures of pain modulation, shoulder pain, disability, range of motion and psychosocial factors were assessed at baseline and immediately after the 4-week period of treatment. Treatment effectiveness was assessed through parametric, non-parametric and multilevel modeling statistics. RESULTS: Twenty-three individuals participatedwith no loss to follow-up. Significant and meaningful improvements in shoulder pain (NRS mean change 1.6/10, 95% CI 0.4 to 2.7), disability (SPADI mean change 20.5/100, 95% CI 13.1 to 27.9) and range of motion (mean change 33°, 95% CI 23 to 43°) were observed following treatment. Statistical but non-clinically meaningful changes were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55). Significant reductions were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55), however these were not considered clinically important. No association was found between clinical characteristics and sensory measures. No association was found between clinical characteristics and sensory measures. CONCLUSION: Glenohumeral mobilization with movement and exercise did not improve pain modulation, despite improvements in pain, function and range of motion, in people with shoulder pain.

Vestibular and oculomotor function in male combat sport athletes.

OBJECTIVES: To investigate for differences in vestibulo-ocular function between active male combat sport athletes and a healthy control group. In addition, to explore the relationship between symptom-based outcome measures with vestibulo-ocular function. DESIGN: Cross-sectional. METHODS: 40 male adult combat sport athletes and 40 active male control participants were recruited from 4 martial arts schools and a University campus in Queensland, Australia. All participants completed a standardised protocol which was used to assess vestibulo-ocular function. The protocol included 3 components: 1) oculomotor function, 2) benign paroxysmal positional vertigo screening, and 3) vestibulo-ocular reflex function. The Post-Concussion Symptom Scale, Vestibular/Ocular Motor Screening tool and Dizziness Handicap Inventory were used as symptom-based outcome measures. RESULTS: More combat sport athletes had oculomotor abnormalities than control group participants. There were no between group differences in benign paroxysmal positional vertigo, vestibulo-ocular reflex function and the video-head impulse test gain (ms). Combat sport athletes had higher symptom-based outcome scores. The Vestibular/Ocular Motor Screening tool and Dizziness Handicap Inventory were found to have moderate positive relationships with the total number of abnormalities detected in the combat sport group. CONCLUSIONS: Vestibulo-ocular function is imperative for combat sport athletes to perform evasive manoeuvres and land their own strikes. The present study findings may aid clinicians in the identification of combat sport athletes with underlying vestibulo-ocular dysfunction, prompting further investigation.

Cervical spine characteristics differ in competitive combat athletes compared with active control participants.

BACKGROUND: Injury to the head and neck are common in combat sport athletes. Impairments of the cervical spine have been found in some athletes who participate in sports with high forces and collisions. There is a lack of research on the effects of combat sports on the cervical spine. OBJECTIVE: The primary study aim was to investigate differences in cervical spine characteristics between combat athletes and a similarly aged active control group. The secondary aim was to investigate the relationship between symptom-based outcome measures and characteristics of the cervical spine. DESIGN: Cross-sectional. METHOD: 40 male adult combat sport athletes and 40 male adult control participants were recruited from 4 combat sport clubs and a university campus, Australia. Cervical spine assessments were conducted at a private physiotherapy clinic. The Neck Disability Index and the Post-Concussion Symptom Scale were used as symptom-based outcome measures. RESULTS: Combat sport athletes had a reduced range of cervical motion, but greater isometric strength and endurance compared with a control group (p < 0.05). The Neck Disability Index and Post-Concussion Symptom Scale were negatively correlated with cervical spine range of motion and isometric strength, meaning that higher scores correlated with a reduction in function. CONCLUSIONS: Differences were observed in characteristics of the cervical spine in combat sport athletes compared with a control group. Higher symptom-based outcome scores correlated with reduced range of motion and strength of cervical spine muscles. Further investigation to establish clinical cut-off scores for functional impairment may be warranted.

The first year of private practice - new graduate physiotherapists are highly engaged and satisfied but edging toward burnout.

BACKGROUND: A greater understanding of physiotherapists' work-life during their first year of work in private practice, and whether their experiences are mediated by personal traits, may provide valuable information to support their transition and retention. OBJECTIVES: Describe the first year of practice for graduate physiotherapists in terms of employee engagement, job satisfaction, performance, and burnout, and evaluate the relationship between these measures and personal traits (resilience, grit, mind-set). DESIGN: One-year longitudinal mixed-methods study. METHODS: Twenty new graduate physiotherapists completed questionnaires evaluating resilience, grit, and mind-set within 1-week of commencing employment. Engagement and job satisfaction were evaluated at 3, 6 and 12-months, and burnout evaluated at 12-months. Performance data (number of patients seen, revenue) were collected throughout the year. Individual semi-structured interviews were conducted at baseline, 3, 9 and 12-months. RESULTS: Engagement and satisfaction were high at all time points. At 12-months, burnout was at a medium level. Resilience was positively associated with job satisfaction at 6 (ρ = 0.56, p = .019) and 12-months (ρ = 0.54, p = .027). Engagement (ρ = -0.57, p = .04) and job satisfaction (ρ = -0.56, p = .03) were negatively associated with burnout at 12-months. All participants remained passionate about their work although increasing administrative burden and patient complexity contributed to feelings of burnout. CONCLUSIONS: Resilience was positively associated with job satisfaction suggesting those with capacity to 'bounce back' were more satisfied and engaged with their job. Although moderate levels of burnout were reported at 12-months, those with higher job satisfaction and employee engagement had lower levels of burnout. Participants proposed practical strategies to help mitigate burnout.

Patient experiences of referral practices and primary care physiotherapy for chronic nonspecific low back pain.

BACKGROUND: Low back pain (LBP) clinical practice guidelines recommend referral for patients with persistent LBP however discordance persists between recommended care and implementation in practice. Understanding patient experiences of referral practices and physiotherapy care could be important for optimizing LBP management in primary care settings. PURPOSE: This study explored referral experiences of people with nonspecific LBP in Australian primary care and their knowledge and experience of physiotherapy. METHODS: An interpretive descriptive qualitative framework was used with 17 participants interviewed from community-based physiotherapy practices. RESULTS: Four themes described the participants' experiences of referrals in primary care settings: 1) Referral practices ranged from formal to informal to non-existent; 2) Fragmented inter-and intra-professional LBP care management; 3) Patient perceived differences in the roles of physiotherapists and specialist physiotherapists; and 4) Patient nominated barriers and facilitators to optimal referral practices. CONCLUSION: Physiotherapists support people with LBP to improve strength and function, whereas the specialist physiotherapist's role was seen as more holistic. Referral pathways that align to clinical guideline recommendations for non-surgical management and treatment remain underdeveloped. Improved referral pathways to clinicians such as physiotherapists with additional credentialed skills and competence in musculoskeletal care could improve people's experiences of care and health outcomes.

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.

Patient perspectives of care pathways for people with low back pain: A qualitative study.

BACKGROUND: Low back pain (LBP) care pathways aim to enhance health outcomes through patient-clinician mutual decision-making and care coordination. However, challenges to successful translation into practice include patients' understanding, expectation, and acceptance of treatment and management strategies for LBP. This study explored patients' perspectives and/or experience of care pathways and their involvement in decision-making in primary care. METHODS: A qualitative descriptive design was adopted. Semi-structured interviews were conducted with 14 participants with LBP recruited from the community. Inductive thematic analysis of the qualitative data was conducted within the design framework to enable a systematic comparison of experiences across participants and within individual cases. RESULTS: Five themes described participant perspectives and understanding of care pathways: i) care pathways can guide decision-making; ii) familiarity with no and/or stepped care pathway, but preference for matched or blend of care pathways; iii) engaging in shared decision-making; iv) patient-related barriers to implementation; v) patient-related facilitators to implementation. CONCLUSIONS: Participants felt that existing care pathways did not meet their needs when pain persisted. Participants preferred matched or hybrid care pathways and suggested that implementation of such pathways should focus on addressing an individual's needs. Adopting a holistic approach, and clarity in shared decision-making, were deemed crucial for effective implementation of LBP pathways in practice. Consumer (patient) engagement in the design of LBP care pathways is recommended.

Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial.

OBJECTIVE: To compare the effectiveness and cost-effectiveness of eccentric loading exercises (ELE) with prolotherapy injections used singly and in combination for painful Achilles tendinosis. DESIGN: A single-blinded randomised clinical trial. The primary outcome measure was the VISA-A questionnaire with a minimum clinically important change (MCIC) of 20 points. SETTING: Five Australian primary care centres. PARTICIPANTS: 43 patients with painful mid-portion Achilles tendinosis commenced and 40 completed treatment protocols. INTERVENTIONS: Participants were randomised to a 12-week program of ELE (n=15), or prolotherapy injections of hypertonic glucose with lignocaine alongside the affected tendon (n=14) or combined treatment (n=14). MAIN OUTCOME MEASUREMENTS: VISA-A, pain, stiffness and limitation of activity scores; treatment costs. RESULTS: At 12 months, proportions achieving the MCIC for VISA-A were 73% for ELE, 79% for prolotherapy and 86% for combined treatment. Mean (95% CI) increases in VISA-A scores at 12 months were 23.7 (15.6 to 31.9) for ELE, 27.5 (12.8 to 42.2) for prolotherapy and 41.1 (29.3 to 52.9) for combined treatment. At 6 weeks and 12 months, these increases were significantly less for ELE than for combined treatment. Compared with ELE, reductions in stiffness and limitation of activity occurred earlier with prolotherapy and reductions in pain, stiffness and limitation of activity occurred earlier with combined treatment. Combined treatment had the lowest incremental cost per additional responder ($A1539) compared with ELE. CONCLUSIONS: For Achilles tendinosis, prolotherapy and particularly ELE combined with prolotherapy give more rapid improvements in symptoms than ELE alone but long-term VISA-A scores are similar. TRIAL REGISTRATION NUMBER: ACTRN: 12606000179538.