Documenting change with the Canadian Occupational Performance Measure for children with cerebral palsy.

AIM: To assess the Canadian Occupational Performance Measure's (COPM) ability to document change over 3 years in children with cerebral palsy (CP). METHOD: This was a prospective study with ambulatory children with CP, aged 2 to 6 years. Caregivers set one to three COPM goals which were rescored annually over 3 years. A ceiling effect for performance goals was operationalized as a score of 8. A Wald χ2 generalized estimating equations model adjusted for age, sex, and Gross Motor Function Classification System (GMFCS) level, evaluated change over time. RESULTS: In total, 124 children (47 [37.9%] females, 77 [62.1%] males; mean age 3y 11mo [SD 1y 1mo]; GMFCS level I [n=78, 62.9%], II [n=21, 16.9%], and III [n=25, 20.2%]) were set 345 COPM goals at baseline. By Year 3, 106 participants (85.5%) rescored 287 of the goals (83.2%). Performance scores increased between baseline mean (SD) 2.93 (0.56), Year 1 5.98 (0.58) with 34.8% at ceiling; Year 2 6.74 (0.60) 48.3% at ceiling; and Year 3 7.37 (0.60) 59.6% at ceiling (Wald χ2 [3]=607.18, p<0.001). Satisfaction scores increased between baseline 4.42 (0.59), Year 1 6.82 (0.60) with 48% at ceiling; Year 2 7.53 (0.60) with 62.2% at ceiling (Wald χ2 [3]=208.48, p<0.001); with no significant increase by Year 3 7.82 (0.62) with 66.9% at ceiling. INTERPRETATION: COPM performance scores increased steadily over 3 years. By Year 2, a ceiling effect was seen in about half of the goals. The COPM may have utility to measure change over 3 years; periodic resetting of the descriptors of goal success are required to minimize ceiling.

Dupuytren's contracture and handwork: A case-control study.

OBJECTIVE: The objective of this study was to examine the association between Dupuytren's contracture (DC), repetitive handwork (RHW), heavy handwork (HHW), and/or vibration exposure. METHODS: Frequency and intensity of the three types of handwork were collected and compared between DC patients and controls. Hours of work were weighted by average "frequency," for RHW, and average "intensity," for HHW and use of vibrating tool. Logistic regression was used to evaluate risk of developing DC associated with the above-mentioned factors. RESULTS: Data from 129 cases (74 clinical, 106 controls) was analyzed. Family history, male gender and age (decades) were associated with increased risk of DC. Results indicate that the risk becomes substantial after about 30 years of steady RHW. Independent effects of intensity-weighted HHW and vibrating exposure were not established. CONCLUSIONS: Frequency-weighted RHW increases DC risk. Additionally, a strong association between DC, male gender and heredity was found.

Population Survey Features and Response Rates: A Randomized Experiment.

OBJECTIVES: To study the effects of several survey features on response rates in a general population health survey. METHODS: In 2012 and 2013, 8000 households in British Columbia, Canada, were randomly allocated to 1 of 7 survey variants, each containing a different combination of survey features. Features compared included administration modes (paper vs online), prepaid incentive ($2 coin vs none), lottery incentive (instant vs end-of-study), questionnaire length (10 minutes vs 30 minutes), and sampling frame (InfoCanada vs Canada Post). RESULTS: The overall response rate across the 7 groups was 27.9% (range = 17.1-43.4). All survey features except the sampling frame were associated with statistically significant differences in response rates. The survey mode elicited the largest effect on the odds of response (odds ratio [OR] = 2.04; 95% confidence interval [CI] = 1.61, 2.59), whereas the sampling frame showed the least effect (OR = 1.14; 95% CI = 0.98, 1.34). The highest response was achieved by mailing a short paper survey with a prepaid incentive. CONCLUSIONS: In a mailed general population health survey in Canada, a 40% to 50% response rate can be expected. Questionnaire administration mode, survey length, and type of incentive affect response rates.

Spinal rehabilitative exercise or manual treatment for the prevention of tension-type headache in adults.

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the short- and long-term effects of manual treatment and spinal rehabilitative exercise for the prevention of tension-type headache in adults.

Spinal rehabilitative exercise or manual treatment for the prevention of cervicogenic headache in adults.

This is the protocol for a review and there is no abstract. The objectives are as follows: To quantify and compare the short- and long-term effects of manual treatment and spinal rehabilitative exercise for cervicogenic headache, classified according to the International Headache Society's (IHS) diagnostic criteria, with an active or placebo/sham comparison or wait-list control.

Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment.

BACKGROUND: Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010. OBJECTIVES: To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes. SEARCH METHODS: Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated. SELECTION CRITERIA: Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs). MAIN RESULTS: We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality). AUTHORS' CONCLUSIONS: Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

Exercises for mechanical neck disorders.

BACKGROUND: Neck pain is common, disabling and costly. Exercise is one treatment approach. OBJECTIVES: To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain. SEARCH METHODS: We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors). SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity. MAIN RESULTS: Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises. AUTHORS' CONCLUSIONS: No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

Inpatient stroke rehabilitation lengths of stay in Canada derived from the National Rehabilitation Reporting System, 2008 and 2009.

OBJECTIVE: To determine rehabilitation length of stay (LOS) for patients with stroke in Canada, and to evaluate which factors contribute to variations in LOS. DESIGN: A retrospective cohort study of Canadians rehabilitating from stroke using medical, functional, and sociodemographic variables extracted from the Canadian Institute for Health Information's National Rehabilitation Reporting System. SETTING: Canadian rehabilitation hospitals providing stroke rehabilitation services. PARTICIPANTS: Patients with stroke (N=11,983) admitted to rehabilitation hospitals from January 2008 through December 2009. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Rehabilitation LOSs were calculated nationally and regionally. Regression models incorporating sociodemographic and clinical measures were constructed to test their effect on LOS. RESULTS: The median stroke rehabilitation LOSs was 35 days (quartiles: 20d, 54d). LOSs varied regionally within Canada. A multivariable regression model including age, FIM motor function scores at admission, and geographic region explained 20% of the variation in LOSs. Modeling these data using a Function-Related Groups case-mix model explained 16% of the variation in LOSs. CONCLUSIONS: FIM motor function scores at admission along with age and geographic region best predicted rehabilitation LOS. These variables explained 20% of the variation in LOSs. Despite regional differences in LOSs, patient characteristics were similar between regions. Other nonpatient factors not captured in these data may contribute to a greater extent in determining stroke rehabilitation LOS.

"Employment and arthritis: making it work" a randomized controlled trial evaluating an online program to help people with inflammatory arthritis maintain employment (study protocol).

BACKGROUND: Arthritis and musculoskeletal conditions are the leading cause of long-term work disability (WD), an outcome with a major impact on quality of life and a high cost to society. The importance of decreased at-work productivity has also recently been recognized. Despite the importance of these problems, few interventions have been developed to reduce the impact of arthritis on employment. We have developed a novel intervention called "Making It Work", a program to help people with inflammatory arthritis (IA) deal with employment issues, prevent WD and improve at-work productivity. After favorable results in a proof-of-concept study, we converted the program to a web-based format for broader dissemination and improved accessibility. The objectives of this study are: 1) to evaluate in a randomized controlled trial (RCT) the effectiveness of the program at preventing work cessation and improving at-work productivity; 2) to perform a cost-utility analysis of the intervention. METHODS/DESIGN: 526 participants with IA will be recruited from British Columbia, Alberta, and Ontario in Canada. The intervention consists of a) 5 online group sessions; b) 5 web-based e-learning modules; c) consultations with an occupational therapist for an ergonomic work assessment and a vocational rehabilitation counselor. Questionnaires will be administered online at baseline and every 6 months to collect information about demographics, disease measures, costs, work-related risk factors for WD, quality of life, and work outcomes. Primary outcomes include at-work productivity and time to work cessation of > 6 months for any reason. Secondary outcomes include temporary work cessation, number of days missed from work per year, reduction in hours worked per week, quality adjusted life year for the cost utility analysis, and changes from baseline in employment risk factors. Analysis of Variance will evaluate the intervention's effect on at-work productivity, and multivariable Cox regression models will estimate the risk of work cessation associated with the intervention after controlling for risk factors for WD and other important predictors imbalanced at baseline. DISCUSSION: This program fills an important gap in arthritis health services and addresses an important and costly problem. Knowledge gained from the RCT will be useful to health care professionals, policy planners and arthritis stakeholders. TRIAL REGISTRATION: ClinicalTrials.gov NCT01852851; registered April 13, 2012; first participant randomized on July 6, 2013.

A tutorial on sensitivity analyses in clinical trials: the what, why, when and how.

BACKGROUND: Sensitivity analyses play a crucial role in assessing the robustness of the findings or conclusions based on primary analyses of data in clinical trials. They are a critical way to assess the impact, effect or influence of key assumptions or variations--such as different methods of analysis, definitions of outcomes, protocol deviations, missing data, and outliers--on the overall conclusions of a study.The current paper is the second in a series of tutorial-type manuscripts intended to discuss and clarify aspects related to key methodological issues in the design and analysis of clinical trials. DISCUSSION: In this paper we will provide a detailed exploration of the key aspects of sensitivity analyses including: 1) what sensitivity analyses are, why they are needed, and how often they are used in practice; 2) the different types of sensitivity analyses that one can do, with examples from the literature; 3) some frequently asked questions about sensitivity analyses; and 4) some suggestions on how to report the results of sensitivity analyses in clinical trials. SUMMARY: When reporting on a clinical trial, we recommend including planned or posthoc sensitivity analyses, the corresponding rationale and results along with the discussion of the consequences of these analyses on the overall findings of the study.

Electrotherapy for neck pain.

BACKGROUND: Neck pain is common, disabling and costly. The effectiveness of electrotherapy as a physiotherapeutic option remains unclear. This is an update of a Cochrane review first published in 2005 and previously updated in 2009. OBJECTIVES: This systematic review assessed the short, intermediate and long-term effects of electrotherapy on pain, function, disability, patient satisfaction, global perceived effect, and quality of life in adults with neck pain with and without radiculopathy or cervicogenic headache. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, without language restrictions, from their beginning to August 2012; handsearched relevant conference proceedings; and consulted content experts. SELECTION CRITERIA: Randomized controlled trials (RCTs), in any language, investigating the effects of electrotherapy used primarily as unimodal treatment for neck pain. Quasi-RCTs and controlled clinical trials were excluded. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. We were unable to statistically pool any of the results, but we assessed the quality of the evidence using an adapted GRADE approach. MAIN RESULTS: Twenty small trials (1239 people with neck pain) containing 38 comparisons were included. Analysis was limited by trials of varied quality, heterogeneous treatment subtypes and conflicting results. The main findings for reduction of neck pain by treatment with electrotherapeutic modalities were as follows.Very low quality evidence determined that pulsed electromagnetic field therapy (PEMF) and repetitive magnetic stimulation (rMS) were more effective than placebo, while transcutaneous electrical nerve stimulation (TENS) showed inconsistent results.Very low quality evidence determined that PEMF, rMS and TENS were more effective than placebo.Low quality evidence (1 trial, 52 participants) determined that permanent magnets (necklace) were no more effective than placebo (standardized mean difference (SMD) 0.27, 95% CI -0.27 to 0.82, random-effects model).Very low quality evidence showed that modulated galvanic current, iontophoresis and electric muscle stimulation (EMS) were not more effective than placebo.There were four trials that reported on other outcomes such as function and global perceived effects, but none of the effects were of clinical importance. When TENS, iontophoresis and PEMF were compared to another treatment, very low quality evidence prevented us from suggesting any recommendations. No adverse side effects were reported in any of the included studies. AUTHORS' CONCLUSIONS: We cannot make any definite statements on the efficacy and clinical usefulness of electrotherapy modalities for neck pain. Since the evidence is of low or very low quality, we are uncertain about the estimate of the effect. Further research is very likely to change both the estimate of effect and our confidence in the results. Current evidence for PEMF, rMS, and TENS shows that these modalities might be more effective than placebo. When compared to other interventions the quality of evidence was very low thus preventing further recommendations.Funding bias should be considered, especially in PEMF studies. Galvanic current, iontophoresis, EMS, and a static magnetic field did not reduce pain or disability. Future trials on these interventions should have larger patient samples, include more precise standardization, and detail treatment characteristics.

Uptake of an innovation in surgery: observations from the cluster-randomized Quality Initiative in Rectal Cancer trial.

BACKGROUND: Theory suggests the uptake of a medical innovation is influenced by how potential adopters perceive innovation characteristics and by characteristics of potential adopters. Innovation adoption is slow among the first 20% of individuals in a target group and then accelerates. The Quality Initiative in Rectal Cancer (QIRC) trial assessed if rectal cancer surgery outcomes could be improved through surgeon participation in the QIRC strategy. We tested if traditional uptake of innovation concepts applied to surgeons in the experimental arm of the trial. METHODS: The QIRC strategy included workshops, access to opinion leaders, intraoperative demonstrations, postoperative questionnaires, and audit and feedback. For intraoperative demonstrations, a participating surgeon invited an outside surgeon to demonstrate optimal rectal surgery techniques. We used surgeon timing in a demonstration to differentiate early and late adopters of the QIRC strategy. Surgeons completed surveys on perceptions of the strategy and personal characteristics. RESULTS: Nineteen of 56 surgeons (34%) requested an operative demonstration on their first case of rectal surgery. Early and late adopters had similar perceptions of the QIRC strategy and similar characteristics. Late adopters were less likely than early adopters to perceive an advantage for the surgical techniques promoted by the trial (p = 0.023). CONCLUSION: Most traditional diffusion of innovation concepts did not apply to surgeons in the QIRC trial, with the exception of the importance of perceptions of comparative advantage.

CONTEXTE: Selon une théorie, 2 facteurs influencent l'adoption de nouvelles pratiques en médecine, soit la façon dont les adeptes potentiels perçoivent les caractéristiques novatrices et les caractéristiques propres aux adeptes potentiels eux-mêmes. L'adoption des nouvelles pratiques se fait lentement chez les premiers 20 % des individus d'un groupe cible, puis va en s'accélérant. L'étude QIRC (Quality Initiative in Rectal Cancer) a voulu vérifier si la participation des chirurgiens à la stratégie QIRC pouvait améliorer l'issue de la chirurgie pour cancer du rectum. Nous avons vérifié si les modes habituels d'adoption des nouvelles pratiques s'appliquaient aux chirurgiens dans le groupe expérimental de l'étude. MÉTHODES: La stratégie QIRC incluait des ateliers, l'accès à des meneurs d'opinion, des démonstrations peropératoires et des questionnaires postopératoires, suivis de vérifications et de commentaires. Pour les démonstrations peropératoires, un chirurgien participant invitait un chirurgien de l'extérieur à faire une démonstration de techniques chirurgicales rectales optimales. Nous avons utilisé les délais d'adoption des nouvelles pratiques par les chirurgiens pour faire ressortir la distinction entre les adeptes précoces et tardifs de la stratégie QIRC. Les chirurgiens ont répondu à des questionnaires sur leurs perceptions à l'endroit de la stratégie et sur leurs caractéristiques personnelles. RÉSULTATS: Dix-neuf chirurgiens sur 56 (34 %) ont demandé une démonstration opératoire lors de leur premier cas de chirurgie rectale. Les adeptes précoces et tardifs avaient des perceptions similaires de la stratégie QIRC et des caractéristiques personnelles similaires. Les adeptes tardifs étaient moins susceptibles que les adeptes précoces de percevoir l'avantage des techniques chirurgicales préconisées dans le cadre de l'étude (p = 0,023). CONCLUSION: La plupart des modes habituels de diffusion des nouvelles pratiques ne s'appliquaient pas aux chirurgiens de l'essai QIRC, à l'exception de l'importance des perceptions à l'endroit des avantages comparatifs.

Patterns of use and outcomes for radiation therapy in the Quality Initiative in Rectal Cancer (QIRC) trial.

BACKGROUND: The Quality Initiative in Rectal Cancer (QIRC) trial targeted surgeon intraoperative technique and not radiation therapy (RT) use. We performed a post hoc analysis of RT use among patients in the QIRC trial, not by arm of trial but rather for the entire group. We wished to identify associations between local recurrence risk and use of preoperative, postoperative or no RT. METHODS: We compared demographic, tumour and process of care measures among patients receiving preoperative, postoperative or no RT. A multivariable Cox regression model assessed local recurrence risk. RESULTS: The QIRC trial enrolled 1015 patients at 16 hospitals between 2002 and 2004. Radiation therapy use did not differ between trial arms, and median follow-up was 3.6 years. For the preoperative, postoperative and no RT groups, respectively, the percentage of patients was 12.8%, 19.3% and 67.9%; the percentage of stage II/III tumours was 57.0%, 88.7% and 48.1%; and the local recurrence rate was 5.3%, 10.2% and 5.5% (p = 0.05). After controlling for patient and tumour characteristics, including tumour stage, the hazard ratio (HR) for local recurrence was increased in the postoperative RT versus the no RT group (HR 1.64, 95% confidence interval 1.04-2.58, p = 0.027). CONCLUSION: Use of preoperative RT was low; most patients with stage II/III disease did not receive RT and, as expected, the postoperative RT group had the highest risk of local recurrence. Our results suggest opportunities to improve rectal cancer RT use in Ontario.

CONTEXTE: L'essai QIRC (Quality Initiative in Rectal Cancer) portait sur la technique peropératoire des chirurgiens et non sur l'utilisation de la radiothérapie (RT). Nous avons effectué une analyse rétrospective de l'utilisation de la RT chez les patients inclus dans l'essai QIRC, non pas en fonction des différents groupes de l'essai, mais en fonction de sa population entière. Nous avons voulu vérifier les liens entre le risque de récurrences locales et l'utilisation préopératoire ou postopératoire de la RT ou l'abstention de toute RT. MÉTHODES: Nous avons comparé les paramètres démographiques, les caractéristiques de la tumeur et le processus de soins chez les patients soumis à une RT préopératoire ou postopératoire, ou non traités par RT. Un modèle de régression multivariée de Cox a permis d'évaluer le risque de récurrences locales. RÉSULTATS: L'essai QIRC a regroupé 1015 patients de 16 hôpitaux entre 2002 et 2004. Le recours à la radiothérapie n'a pas différé entre les groupes de l'essai, et le suivi médian a été de 3,6 ans. Pour ce qui est des groupes soumis à une RT préopératoire ou postopératoire, ou non soumis à la RT, respectivement, le pourcentage de patients était de 12,8 %, 19,3 % et 67,9 %; le pourcentage de tumeurs de stade II/III était de 57,0 %, 88,7 % et 48,1 %, et le taux de récurrences locales, de 5,3 %, 10,2 % et 5,5 % (p = 0,05). Après ajustement pour tenir compte des caractéristiques des patients et des tumeurs, y compris le stade de la tumeur, le risque relatif (RR) de récurrences locales a augmenté dans le groupe soumis à une RT postopératoire par rapport au groupe non soumis à la RT (RR 1,64; intervalle de confiance de 95 %, 1,04­2,58, p = 0,027). CONCLUSION: Le recours à la RT préopératoire a été faible; la plupart des patients atteints d'une maladie de stade II/III n'ont pas reçu de RT et comme prévu, le groupe soumis à une RT postopératoire a présenté le risque le plus élevé de récurrences locales. Nos résultats indiquent qu'il serait possible d'améliorer l'utilisation de la RT pour le cancer rectal en Ontario.

Exercises for mechanical neck disorders.

BACKGROUND: Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear. OBJECTIVES: To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain. SEARCH METHODS: Computerized searches were conducted up to February 2012. SELECTION CRITERIA: We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses. MAIN RESULTS: Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term. AUTHORS' CONCLUSIONS: Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.

Massage for mechanical neck disorders.

BACKGROUND: The prevalence of mechanical neck disorders (MND) is known to be both a hindrance to individuals and costly to society. As such, massage is widely used as a form of treatment for MND. OBJECTIVES: To assess the effects of massage on pain, function, patient satisfaction, global perceived effect, adverse effects and cost of care in adults with neck pain versus any comparison at immediate post-treatment to long-term follow-up. SEARCH METHODS: We searched The Cochrane Library (CENTRAL), MEDLINE, EMBASE, MANTIS, CINAHL, and ICL databases from date of inception to 4 Feburary 2012. SELECTION CRITERIA: Studies using random assignment were included. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted citation identification, study selection, data abstraction and methodological quality assessment. Using a random-effects model, we calculated the risk ratio and standardised mean difference. MAIN RESULTS: Fifteen trials met the inclusion criteria. The overall methodology of all the trials assessed was either low or very low GRADE level. None of the trials were of strong to moderate GRADE level. The results showed very low level evidence that certain massage techniques (traditional Chinese massage, classical and modified strain/counter strain technique) may have been more effective than control or placebo treatment in improving function and tenderness. There was very low level evidence that massage may have been more beneficial than education in the short term for pain bothersomeness. Along with that, there was low level evidence that ischaemic compression and passive stretch may have been more effective in combination rather than individually for pain reduction. The clinical applicability assessment showed that only 4/15 trials adequately described the massage technique. The majority of the trials assessed outcomes at immediate post-treatment, which is not an adequate time to assess clinical change. Due to the limitations in the quality of existing studies, we were unable to make any firm statement to guide clinical practice. We noted that only four of the 15 studies reported side effects. All four studies reported post-treatment pain as a side effect and one study (Irnich 2001) showed that 22% of the participants experienced low blood pressure following treatment. AUTHORS' CONCLUSIONS: No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.As a stand-alone treatment, massage for MND was found to provide an immediate or short-term effectiveness or both in pain and tenderness. Additionally, future research is needed in order to assess the long-term effects of treatment and treatments provided on more than one occasion.

Patient education for neck pain.

BACKGROUND: Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear. OBJECTIVES: To assess the short- to long-term effects of therapeutic patient education (TPE) strategies on pain, function, disability, quality of life, global perceived effect, patient satisfaction, knowledge transfer, or behaviour change in adults with neck pain associated with whiplash or non-specific and specific mechanical neck pain with or without radiculopathy or cervicogenic headache. SEARCH METHODS: We searched computerised bibliographic databases (inception to 11 July 2010). SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCT) investigating the effectiveness of TPE for acute to chronic neck pain. DATA COLLECTION AND ANALYSIS: Paired independent review authors conducted selection, data abstraction, and 'Risk of bias' assessment. We calculated risk ratio (RR) and standardised mean differences (SMD). Heterogeneity was assessed; no studies were pooled. MAIN RESULTS: Of the 15 selected trials, three were rated low risk of bias. Three TPE themes emerged.Advice focusing on activation: There is moderate quality evidence (one trial, 348 participants) that an educational video of advice focusing on activation was more beneficial for acute whiplash-related pain when compared with no treatment at intermediate-term [RR 0.79 (95% confidence interval (CI) 0.59 to 1.06)] but not long-term follow-up [0.89 (95% CI, 0.65 to 1.21)]. There is low quality evidence (one trial, 102 participants) that a whiplash pamphlet on advice focusing on activation is less beneficial for pain reduction, or no different in improving function and global perceived improvement from generic information given out in emergency care (control) for acute whiplash at short- or intermediate-term follow-up. Low to very low quality evidence (nine trials using diverse educational approaches) showed either no evidence of benefit or difference for varied outcomes. Advice focusing on pain & stress coping skills and workplace ergonomics: Very low quality evidence (three trials, 243 participants) favoured other treatment or showed no difference spanning numerous follow-up periods and disorder subtypes.  Low quality evidence (one trial, 192 participants) favoured specific exercise training for chronic neck pain at short-term follow-up.Self-care strategies: Very low quality evidence (one trial, 58 participants) indicated that self-care strategies did not relieve pain for acute to chronic neck pain at short-term follow-up. AUTHORS' CONCLUSIONS: With the exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies. Future research should be founded on sound adult learning theory and learning skill acquisition.

Improving the Science in Plastic Surgery.

SUMMARY: In 1906, George Bernard Shaw criticized the medical profession for its lack of science and compassion. Since then, advances in both medical and surgical subspecialties have improved quality of patient care. Unfortunately, the reporting of these advances is variable and is frequently biased. Such limitations lead to false claims, wasted research dollars, and inability to synthesize and apply evidence to practice. It was hoped that the introduction of evidence-based medicine would improve the quality of health care and decrease health dollar waste. For this to occur, however, credible "best evidence"-one of the components of evidence-based medicine-is required. This article provides a framework for credible research evidence in plastic surgery, as follows: (1) stating the clinical research question, (2) selecting the proper study design, (3) measuring critical (important) outcomes, (4) using the correct scale(s) to measure the outcomes, (5) including economic evaluations with clinical (effectiveness) studies, and (6) reporting a study's results using the Enhancing the Quality and Transparency of Health Research, or EQUATOR, guidelines. Surgeon investigators are encouraged to continue improving the science in plastic surgery by applying the framework outlined in this article. Improving surgical clinical research should decrease resource waste and provide patients with improved evidence-based care.

The effect of ultrasound or phonophoresis as an adjuvant treatment for non-specific neck pain: systematic review of randomised controlled trials.

OBJECTIVE: To determine the effectiveness of ultrasound/phonophoresis as an adjuvant to exercise or manual therapy for the improvement of patient-centred outcomes in adults with non-specific neck pain (NSNP). METHODS: Seven electronic databases were systematically searched up to September 2020. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to judge the Quality of Evidence (QoE). RESULTS: Six studies involving 249 participants were included. The QoE was very low GRADE. Phonophoresis with capsaicin plus exercise improved pain at immediate post-treatment (MD: -3.30 [-4.05, -2.55]) but not with diclofenac sodium plus exercise as compared to exercise. Continuous ultrasound (CUS) plus exercise improved pain and pressure pain threshold (PPT) at immediate post-treatment (pain: MD: -3.42 [-4.08, -2.7]); (PPT: MD: 0.91 [0.68, 1.14]) and at intermediate-term as compared to exercise. CUS or high power pain threshold (HPPT) ultrasound plus manual therapy and exercise showed no benefit for pain reduction (MD: -0.75 [-2.08, 0.58]) did not improve function/disability (MD: -1.05 [-4.27, 2.17]) at immediate or short-term as compared to manual therapy and exercise. CONCLUSIONS: Due to high risk of bias, inconsistency, and indirectness the QoE is very low in support of benefit of ultrasound/phonophoresis as an adjuvant treatment for NSNP.Implication for rehabilitationDue to high risk of bias, inconsistency, and indirectness the quality of evidence (QoE) is very low in support of benefit of adding ultrasound or phonophoresis to exercise or manual therapy for pain reduction or improvement in function/disability for those with sub-acute and chronic myofascial associated neck pain. However, our confidence in the findings is very low and conclusions are likely to change as more evidences emerges.Clinicians using ultrasound therapy as an adjuvant intervention for management of chronic myofascial associated neck pain should carefully consider the available evidence on ultrasound, including the benefits and costs involved.

Pilot of a Training Format for Clinicians' Continuing Professional Development: Open House With Rotating Short Segments.

INTRODUCTION: Access to continuing professional development offered at lunchtime is limited by hospital scheduling that has staff members taking their lunch breaks at different times. To overcome this barrier, we developed a three-part training format with (1) a focus group segment soliciting participants' opinions on the training's target behavior, (2) a didactic segment introducing tools to support the behavior, and (3) a question-and-answer segment about the session topic. We rotated through these segments, each 15 minutes long, over 3 hours. Participants could join at any segment and experience the full curriculum after 45 minutes. METHODS: We piloted this training format five times at three hospitals. Our training aimed to encourage clinicians to consistently inform involuntary patients about their Mental Health Act rights. We gauged the effect of the training and participants' opinions of the session using the Continuing Professional Development Reaction questionnaire and a session evaluation, respectively. RESULTS: Continuing Professional Development-Reaction results (n = 80) showed a detectable increase in clinicians' intent to consistently give involuntary patients rights advice. Participants reported finding the training organized, informative, and valuable. DISCUSSION: The open house with rotating short segments is a feasible and adaptable training format to engage clinicians in voluntary continuing professional development.