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

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

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

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

Effect of Probiotic, Prebiotic, and Synbiotic Supplementation on Cardiometabolic and Oxidative Stress Parameters in Patients With Chronic Kidney Disease: A Systematic Review and Meta-analysis.

PURPOSE: Chronic kidney disease (CKD) is a major health problem worldwide. Evidence supporting the use of probiotic, prebiotic, and synbiotic supplementation in the management of CKD is mixed, although some studies suggest they may be useful. A systematic review and meta-analysis was performed to evaluate the effectiveness of probiotic, prebiotic, and synbiotic supplementation for improving cardiometabolic and oxidative stress parameters in patients with CKD. METHODS: A comprehensive key word search was performed in EMBASE, Medline, Scopus, Cochrane Central, and Web of Science until April 2020. Randomized controlled trials investigating the effectiveness of probiotic, synbiotic, and prebiotic supplementation for the management of adults with CKD were included. Primary outcomes were measures of cardiometabolic parameters such as cholesterol and fasting blood glucose. Secondary outcomes were measures of oxidative stress (eg, malondialdehyde levels) and body mass index. Random effects meta-analyses were used to estimate mean treatment effects. Results are reported as standardized mean differences (SMDs) and 95% CIs. FINDINGS: Fourteen articles were included. In patients with CKD, probiotic, prebiotic, and synbiotic supplementation significantly reduced total cholesterol (SMD, -0.25; 95% CI, -0.46 to -0.04; I2 = 00.0%), fasting blood glucose (SMD, -0.41; 95% CI, -0.65 to -0.17; I2 = 00.0%), homeostatic model assessment of insulin resistance (SMD, -0.63; 95% CI, -0.95 to -0.30; I2 = 43.3%), insulin levels (SMD, -0.49; 95% CI, -0.90 to -0.08; I2 = 65.2%), high-sensitivity C-reactive protein levels (SMD, -0.52; 95% CI, -0.81 to -0.22; I2 = 52.7%), and malondialdehyde levels (SMD, -0.79; 95% CI, -1.22 to -0.37; I2 = 69.8%) compared with control interventions. Supplementation significantly increased the quantitative insulin sensitivity check index (SMD, 0.78; 95% CI, 0.51 to 1.05; I2 = 00.0%), total antioxidant capacity (SMD, 0.42; 95% CI, 0.18 to 0.66; I2 = 00.0%), and glutathione levels (SMD, 0.52; 95% CI, 0.19 to 0.86; I2 = 37.0%). IMPLICATIONS: Probiotic, prebiotic, and synbiotic supplementation seems to be a promising intervention for improving cardiometabolic and oxidative stress parameters in patients with CKD.

The effectiveness of biofeedback for improving pain, disability and work ability in adults with neck pain: A systematic review and meta-analysis.

BACKGROUND: Biofeedback is used to optimise muscle activation patterns in people with neck pain. OBJECTIVES: To evaluate the safety and efficacy of electromyographic and pressure biofeedback on pain, disability and work ability in adults with neck pain. DESIGN: Systematic review and meta-analysis. METHODS: We searched key databases and trial registries to September 2020, using terms synonymous with 'neck pain' and 'biofeedback'. We included randomised controlled trials (RCTs) evaluating biofeedback (against any comparison) for adults with neck pain. Outcomes included pain, disability, work ability and adverse events. Two authors independently selected the studies, extracted data, and evaluated risk of bias. GRADE was applied to each meta-analysis. Data were pooled using random-effects models to determine the standardised mean change (SMC). RESULTS: We included 15 RCTs (n = 990). Moderate-quality evidence suggests biofeedback has a moderate effect on reducing short-term disability (SMC = -0.42, 95%CI: 0.59 to -0.26, nine trials, n = 627), and a small effect on reducing intermediate-term disability (SMC = -0.30, 95%CI: 0.53 to -0.06, five trials, n = 458). Biofeedback had no effect on pain or work ability in the short- and intermediate-term (low-to moderate-quality evidence). One study reported headaches in 6.7% of participants, but headache frequency was not reported by group. LIMITATIONS: There were a variety of control interventions across studies. Few studies compared biofeedback with no treatment or placebo. CONCLUSION: Biofeedback appears to have a small-to-moderate effect on reducing neck pain disability in the short- and intermediate-term, but no effect on pain or work ability. More trials reporting adverse events and comparing biofeedback to placebo are needed.

Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review.

OBJECTIVES: Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews. DESIGN: Systematic review. SETTING: We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018. PARTICIPANTS: Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion. PRIMARY AND SECONDARY OUTCOMES: Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes). RESULTS: We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits). CONCLUSIONS: Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended. PROSPERO REGISTRATION NUMBER: CRD42018094979.

Physiotherapists' views on the Australian Physiotherapy Association's Choosing Wisely recommendations: a content analysis.

OBJECTIVES: Choosing Wisely holds promise for increasing awareness of low-value care in physiotherapy. However, it is unclear how physiotherapists' view Choosing Wisely recommendations. The aim of this study was to evaluate physiotherapists' feedback on Choosing Wisely recommendations and investigate agreement with each recommendation. SETTING: The Australian Physiotherapy Association emailed a survey to all 20 029 physiotherapist members in 2015 seeking feedback on a list of Choosing Wisely recommendations. PARTICIPANTS: A total of 9764 physiotherapists opened the email invitation (49%) and 543 completed the survey (response rate 5.6%). Participants were asked about the acceptability of the wording of recommendations using a closed (Yes/No) and free-text response option (section 1). Then using a similar response format, participants were asked whether they agreed with each Choosing Wisely recommendation (sections 2-6). PRIMARY AND SECONDARY OUTCOMES: We performed a content analysis of free-text responses (primary outcome) and used descriptive statistics to report agreement and disagreement with each recommendation (secondary outcome). RESULTS: There were 872 free-text responses across the six sections. A total of 347 physiotherapists (63.9%) agreed with the 'don't' style of wording. Agreement with recommendations ranged from 52.3% (electrotherapy for back pain) to 76.6% (validated decision rules for imaging). The content analysis revealed that physiotherapists felt that blanket rules were inappropriate (range across recommendations: 13.9%-30.1% of responses), clinical experience is more valuable than evidence (11.7%-28.3%) and recommendations would benefit from further refining or better defining key terms (7.3%-22.4%). CONCLUSIONS: Although most physiotherapists agreed with both the style of wording for Choosing Wisely recommendations and with the recommendations, their feedback highlighted a number of areas of disagreement and suggestions for improvement. These findings will support the development of future recommendations and are the first step towards increasing the impact Choosing Wisely has on physiotherapy practice.

Is Vitamin D Supplementation Effective for Low Back Pain? A Systematic Review and Meta-Analysis.

BACKGROUND: Low back pain (LBP) is the leading cause of years lived with disability worldwide. Current intervention strategies are failing to reduce the enormous global burden of LBP and are prompting researchers to investigate alternative management strategies, such as vitamin D supplementation. Vitamin D supplementation appears to down regulate pro-inflammatory cytokines which lead to pain and up regulate anti-inflammatory cytokines that reduce inflammation. These mechanisms might explain the increasing interest in the use of vitamin D supplementation for LBP. OBJECTIVES: To determine whether vitamin D supplementation improves pain more than a control intervention for individuals with LBP. STUDY DESIGN: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. METHODS: We performed searches in numerous electronic databases combining key words relating to "vitamin D" and "LBP" until March 2017. Studies were included if they investigated vitamin D supplementation in participants with LBP, provided there was a comparison intervention. There was no restriction on the type of LBP, the intervention parameters investigated, or the type of clinical trial (e.g., randomized, non-randomized). Two reviewers independently performed the selection of studies, extracted data, rated the methodological quality of the included studies, and evaluated the overall quality of the evidence using the Grading of Recommendations Assessment, Delevopment, and Evaulation (GRADE) approach. RESULTS: After screening 3,534 articles, 8 clinical trials were included in this systematic review. There is very low quality evidence (based on the GRADE approach) that vitamin D supplementation is not more effective than any intervention (including placebo, no intervention, and other conservative/pharmacological interventions) (continuous pain measures [0-100]: mean difference [MD] = -2.65, 95% confidence interval [CI]: -10.42 to 5.12, P = 0.504, n = 5; self-reported reduction in pain: pooled odds ratio [OR] = 1.07, 95% CI: 0.35 to 3.26, P = 0.906, n = 5) or placebo/no intervention for individuals with LBP (continuous pain measures: MD = 1.29, 95% CI: -3.81 to 6.39, P = 0.620, n = 4; self-reported reduction in pain: pooled OR = 1.53, 95% CI: 0.38 to 6.20, P = 0.550, n = 4), where 'n' is the number of studies included in the meta-analysis. These results did not change when we stratified the meta-analyses by the type of vitamin supplementation (vitamin D3 vs. alfacalcidol) or the type of LBP (non-specific vs. LBP resulting from osteoporosis or vertebral fractures). LIMITATIONS: The overall quality of evidence was "very low" due to the poor methodological quality and small sample sizes of the included studies. CONCLUSIONS: Vitamin D supplementation is not more effective than placebo, no intervention, or other conservative/pharmacological interventions for LBP (based on very low quality evidence). These results are consistent, regardless of the type of LBP or vitamin D supplementation. Until well-designed and adequately powered clinical trials suggest otherwise, the prescription of vitamin D for LBP cannot be recommended. PROSPERO Registration No: CRD42016046874. www.crd.york.ac.uk/PROSPERO/display_record.asp?ID = CRD42016046874. KEY WORDS: Vitamin D, low back pain, chronic low back pain, alfacalcidol, osteoporosis, vertebral fractures, serum 25-hydroxyvitamin D, systematic review.

Mapping the Association between Vitamin D and Low Back Pain: A Systematic Review and Meta-Analysis of Observational Studies.

BACKGROUND: Low back pain (LBP) is the highest contributor to disability worldwide, with current intervention strategies only providing small to moderate analgesic effects. The use of vitamin D supplementation for LBP has gained interest due to its proposed anti-inflammatory and neuromodulatory properties. However, it is still unclear whether vitamin D levels differ between those with and without LBP or if vitamin D levels are associated with pain intensity. OBJECTIVES: We aim to investigate the association between vitamin D levels and LBP and to determine if vitamin D levels correlate with pain intensity in individuals with LBP. STUDY DESIGN: This study was conducted in accordance with the guidelines for performing a Meta-analysis and Systematic Review Of Observational Studies in Epidemiology (MOOSE). METHODS: We performed electronic database searches combined keywords relating to vitamin D and LBP in MEDLINE, CINAHL, EMBASE, AMED, WEB OF SCIENCE, and SCOPUS from the earliest record to March 2017. Studies were included if they reported any quantitative measure of vitamin D, such as serum 25-hydroxyvitamin D [25(OH)D], with adequate data in patients with and without LBP or adequate data on pain intensity in patients with LBP. No restriction on the type or duration of LBP, nor the age and gender of patients was applied. Two reviewers independently performed the selection of studies, extracted data, and assessed the methodological quality of the included studies using a modified 15-item Downs and Black checklist. RESULTS: After the removal of duplicates and the screening of titles and abstracts, 105 full texts were evaluated. There were 29 articles included in this systemic review (22 entered into a meta-analysis), including 19 cross-sectional studies, 9 case-control studies, and one single-arm surgical trial where the pre-operative data were used in our analyses. The pooled results from 19 studies showed that individuals with LBP were more likely to have vitamin D deficiency (pooled OR = 1.60, 95% CI: 1.20 - 2.12, P = 0.001, n = 19), severe deficiency (pooled OR = 2.08, 95% CI: 1.19 - 3.64, P = 0.010, n = 7), and lower serum concentrations of 25(OH)D (weighted MD = 3.86, 95% CI: 0.20 - 7.52, P = 0.039, n = 12) compared to those without LBP (where "n" is the number of studies). The association between vitamin D deficiency (pooled OR = 1.83, 95% CI: 1.26 - 2.66, P = 0.002, n = 9) or serum 25(OH)D (weighted MD = 7.64, 95% CI: 4.02 - 11.26, P < 0.001, n = 4) and LBP was stronger for women but failed to be statistically significant for men (pooled OR = 1.06, 95% CI: 0.62 - 1.81, P = 0.213, n = 3). In addition, there were strong associations between vitamin D deficiency and LBP in patients < 60 years old (particularly women). We found minimal evidence to support an association between vitamin D levels and pain intensity in patients with LBP. LIMITATIONS: We were unable to investigate whether vitamin D deficiency increases the risk of developing LBP as there were no longitudinal studies included in this review. CONCLUSION: Vitamin D deficiency is associated with LBP, with stronger associations observed in younger women and those with severe levels of deficiency. The association between vitamin D levels and pain intensity is inconsistent. These results may guide the implementation of future studies on vitamin D supplementation for LBP. PROSPERO Registration No: CRD42016046874. KEY WORDS: Vitamin D, low back pain, deficiency, pain intensity, serum 25-hydroxyvitamin D, supplementation, cross-sectional study, case-control study.