Evaluation of methodological and reporting quality of systematic reviews on conservative non-pharmacological musculoskeletal pain management in children and adolescents: A methodological analysis.

BACKGROUND: There are no studies investigating the methodological and report quality of systematic reviews of non-pharmacological interventions for musculoskeletal pain management among children and adolescents. OBJECTIVE: To evaluate the methodological and reporting quality of systematic reviews on conservative non-pharmacological pain management in children and adolescents with musculoskeletal pain. METHODS: Searches were conducted on the Cochrane Database of Systematic Reviews, Medline, Embase, and three other databases. Two pairs of reviewers independently assessed each article according to the predetermined selection criteria. We assessed the methodological quality of systematic reviews, using the AMSTAR 2 checklist and the quality of reporting, using PRISMA checklist. Descriptive analysis was used to summarise the characteristics of all included systematic reviews. The percentage of systematic reviews achieving each item from the AMSTAR 2, PRISMA checklist and the overall confidence in the results were described. RESULTS: We included 17 systematic reviews of conservative non-pharmacological pain management for musculoskeletal pain in children and adolescents. Of the 17 systematic reviews included, nine (53%) were rated as "critically low", seven (41%) were rated as "low", and one (6%) was rated as "high" methodological quality by AMSTAR-2. The reporting quality by items from PRISMA range from 17.6% (95% CI 6.2 to 41) to 100% (95% CI 81.6 to 100). CONCLUSION: This systematic review of physical interventions in children and adolescents showed overall 'very low' to 'high' methodological quality and usually poor reporting quality.

Translation, cross-cultural adaptation and measurement properties of three implementation measures into Brazilian-Portuguese.

BACKGROUND: To translate and cross-culturally adapt into Brazilian-Portuguese, and to test the measurement properties of the following items of implementation outcome measures: Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM) and Feasibility of Intervention Measure (FIM). METHODS: This was a measurement properties study in accordance with the Consensus-based Standards for the selection of health status Measurement Instruments (COSMIN). We conducted a translation and cross-cultural adaptation of three implementation measures according to guidelines for translation and cross-cultural adaptation, then we collected information from patients who had participated in remotely delivered physical therapy treatment for musculoskeletal condition. The patients answered the translated versions of the implementation outcome measures. The measurement properties of the three implementation outcome measures were collected in a test-retest assessment, with an interval of 7 to 14 days.. The measurement properties evaluated in this study were interpretability, measured using Ceiling and Floor Effects, reliability in test-retest evaluation, measured using Cronbach's Alpha Coefficient, internal consistency, measured using Intraclass Correlation Coefficient and construct validity, measured using Pearson Correlation. RESULTS: We included 104 participants (76 female). The average age of the sample was 56.8 (SD 14.8) years old. The items of implementation outcome measures (AIM, IAM, and FIM) showed 66.39%, 63.11%, and 63.93% of ceiling effects. The items of implementation outcome measures showed adequate internal consistency measured using Cronbach's Alpha Coefficient (AIM: 0.89, IAM: 0.91, FIM: 0.93) and values of Standard Error of Measurement between 5 and 10%, showing good measurement error. The results of AIM and IAM was classified as moderate reliability and the FIM as substantial reliability. In a total 96 correlations, > 75% of correlations met our prior hypothesis. CONCLUSION: The three Brazilian-Portuguese versions of items of implementation outcome measures had adequate internal consistency, measurement error and construct validity. The three implementation outcome measures showed moderate to substantial reliability values. The Ceiling Effect was observed in the three measures, showing maximum values ​​in more than 15% of the evaluations.

The state of the art in telerehabilitation for musculoskeletal conditions.

BACKGROUND: Given the rapid advances in communication technology and the need that emerged from the COVID-19 pandemic, telehealth initiatives have been widely used worldwide. This masterclass aims to provide an overview of telerehabilitation for musculoskeletal conditions, synthesizing the different terminologies used to describe telehealth and telerehabilitation, its effectiveness and how to use it in clinical practice, barriers and facilitators for the implementation in health services, and discuss the need of a curriculum education for the near future. MAIN BODY: Telerehabilitation refers to the use of information and communication technologies provided by any healthcare professionals for rehabilitation services. Telerehabilitation is a safe and effective option in the management of musculoskeletal conditions in different models of delivery. There are many technologies, with different costs and benefits, synchronous and asynchronous, that can be used for telerehabilitation: telephone, email, mobile health, messaging, web-based systems and videoconferences applications. To ensure a better practice of telerehabilitation, the clinician should certify safety and access, and appropriateness of environment, communication, technology, assessment, and therapeutic prescription. Despite the positive effect of telerehabilitation in musculoskeletal disorders, a suboptimal telerehabilitation implementation may have happened due to the COVID-19 pandemic, especially in countries where telehealth was not a reality, and clinicians lacked training and guidance. This emphasizes the need to identify the necessary curriculum content to guide future clinicians in their skills and knowledge for telerehabilitation. There are some challenges and barriers that must be carefully accounted for to contribute to a health service that is inclusive and relevant to health professionals and end users. CONCLUSIONS: Telerehabilitation can promote patient engagement in health care and plays an important role in improving health outcomes in patients with musculoskeletal conditions. Digital health technologies can also offer new opportunities to educate patients and facilitate the process of behavior change to a healthy lifestyle. Currently, the main needs in telerehabilitation are the inclusion of it in health curriculums in higher education and the development of cost-effectiveness and implementation trials, especially in low- and middle-income countries where access, investments and digital health literacy are limited.

Feasibility, Usability, and Implementation Context of an Internet-Based Pain Education and Exercise Program for Chronic Musculoskeletal Pain: Pilot Trial of the ReabilitaDOR Program.

BACKGROUND: Internet-based self-management programs and telerehabilitation initiatives have increased and have been extensively used for delivering health care in many areas. These programs overcome common barriers that patients face with traditional face-to-face health care, such as travel expenditures, lack of time, and high demand on the public health system. During the COVID-19 pandemic, this mode of web-based health care delivery had become more popular. However, there is still a lack of studies testing this mode of delivery in low- and middle-income countries. To gain a better understanding of the context, feasibility, and factors involved in the implementation of a web-based program, pilot and implementation studies are necessary. These studies can better inform whether a strategy is feasible, acceptable, and adequate for its purposes and for optimizing resource allocation. OBJECTIVE: This study aims to evaluate the feasibility, usability, and implementation context of a self-management internet-based program based on exercises and pain education (ReabilitaDOR) in people with chronic musculoskeletal pain and to compare this program with a program using only a web-based self-management booklet. METHODS: The study design was a parallel pilot study of a prospectively registered, assessor-blinded, 2-arm randomized controlled trial with economic evaluation. This study was performed using waiting lists of physiotherapy and rehabilitation centers and advertisements on social media networks. The participants were 65 patients with chronic musculoskeletal pain aged between 18 and 60 years. The effects of an 8-week telerehabilitation program based on exercises and pain education (intervention group) were compared with those of a program based only on a web-based self-management booklet (control group). The main outcome measures were implementation outcomes of patients' perceptions of acceptability, appropriateness, feasibility, and usability of the program and the societal costs and feasibility of the main trial at 8-week posttreatment follow-up. Adverse events were also analyzed. RESULTS: In total, 56 participants were analyzed at the 8-week follow-up. The intervention group showed responses with a mean of 4.5 (SD 0.6) points for acceptability, 4.5 (SD 0.5) points for appropriateness, and 4.5 (SD 0.6) points for feasibility measured on a 1 to 5 scale. All patients in the intervention group showed satisfactory responses to the system usability outcome. There is satisfactory evidence for the feasibility of the main trial. For costs related to the interventions, health care, patients, and loss of productivity at 8 weeks, we found a total expenditure of US $278.30 per patient in the intervention group and US $141.52 per patient in the control group. No adverse events were reported during the intervention period. CONCLUSIONS: We found that the ReabilitaDOR program is feasible, appropriate, and acceptable from the users' implementation perspective. This system was considered usable by all the participants, and the main trial seemed feasible. Cost data were viable to be collected, and the program is likely to be safe. TRIAL REGISTRATION: ClinicalTrials.gov NCT04274439; https://clinicaltrials.gov/ct2/show/NCT04274439.

At my own pace, space, and place: a systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain.

ABSTRACT: Telehealth is a promising approach to support self-management with the potential to overcome geographical barriers. Understanding patient perspectives will identify practical challenges to delivering self-management strategies by telehealth. The aim of this study was to synthesize the perceptions of people with chronic musculoskeletal pain for engaging in interventions delivered using telehealth. We searched MEDLINE, Embase, CINAHL, LILACS, and PsycINFO databases. We included qualitative studies that explored perceptions or experiences or attitudes of people with chronic musculoskeletal pain engaging with telehealth. We assessed the methodological quality using the Critical Appraisal Skills Programme checklist. Meta-synthesis was guided by a thematic synthesis approach. The level of confidence of review findings was assessed using the Confidence in the Evidence from Reviews of Qualitative Studies (GRADE-CERQual). Twenty-one studies were included (n = 429). Telehealth comprised web-based, videoconference-based, telephone-based, video-based, and smartphone app-based programs delivered solely or combined. Chronic musculoskeletal conditions included people with knee or hip osteoarthritis, chronic low back pain, persistent pain (chronic joint pain or nonspecific chronic musculoskeletal pain), rheumatoid arthritis, and functional fatigue syndrome. The enablers for engaging in telehealth interventions were as follows: (1) "at my own pace, space, and place" and (2) empowered patient. Barriers to engaging in telehealth interventions were as follows: (1) impersonal, (2) technological challenges, (3) irrelevant content, and (4) limited digital (health) literacy. Telehealth interventions with well-designed interactive platforms, flexibility to fit patients' routine, and the broad availability of material may favor better engagement. Encouragement of self-efficacy is linked to successful telehealth-delivered self-management programs.

The Effectiveness of Strategies to Promote Walking in People With Musculoskeletal Disorders: A Systematic Review With Meta-analysis.

OBJECTIVE: To evaluate the effect of walking promotion strategies on physical activity, pain, and function in people with musculoskeletal disorders. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We performed the searches in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Physiotherapy Evidence Database (PEDro) from inception to August 2019. STUDY SELECTION CRITERIA: We included randomized controlled trials evaluating interventions that promote walking in people with musculoskeletal disorders. DATA SYNTHESIS: We used the PEDro scale for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence. We expressed pooled effects for between-group differences as mean differences or standardized mean differences and 95% confidence intervals, or as risk ratios and 95% confidence intervals, using random-effects meta-analyses. RESULTS: Twelve eligible trials (n = 1456 participants) were identified. There was moderate- to very low-quality evidence of no difference in physical activity levels for walking promotion interventions when compared to minimal interventions, and a significant effect favoring walking promotion when compared with usual care in the short term. There was moderate-quality evidence that walking promotion was modestly effective for reducing pain and improving function compared with minimal intervention and usual care. There was no difference in pain and function for walking promotion compared to supervised exercise. Walking promotion was not associated with different rates of adverse events compared to control conditions. CONCLUSION: Strategies to promote walking did not increase physical activity in people with musculoskeletal disorders. Walking promotion was associated with small improvements in pain and function compared to minimal intervention and usual care. J Orthop Sports Phys Ther 2020;50(11):597-606. doi:10.2519/jospt.2020.9666.

Evaluation of the efficacy of an internet-based pain education and exercise program for chronic musculoskeletal pain in comparison with online self-management booklet: a protocol of a randomised controlled trial with assessor-blinded, 12-month follow-up, and economic evaluation.

BACKGROUND: Chronic musculoskeletal pain is one of the main causes of years lived with disability and generates the highest cost of health care among chronic pain conditions. Internet-based treatments have been shown to be an alternative for the treatment of musculoskeletal conditions, in addition to reducing barriers such as travel, high demands on the public health system, lack of time, lack of insurance coverage for private care, and high costs for long-term treatment. The aim of this clinical trial is to develop and test the effectiveness and cost-effectiveness of, an internet-based self-management program based on pain education and exercise for people with chronic musculoskeletal pain. METHODS: This is a prospectively registered, assessor-blinded, two-arm randomised controlled trial with economic evaluation comparing the Internet-based pain education and exercise intervention with a control group that will receive an online booklet. One hundred and sixty patients will be recruited from Sao Paulo, Brazil. Follow-ups will be conducted in post-treatment, 6 and 12 months after randomisation. The conduct of the study, as well as the evaluations and follow-ups will be carried out entirely remotely, through online platforms and telephone calls. The primary outcome will be pain intensity at post-treatment (8 weeks) measured using the 11-item Pain Numerical Rating Scale. Secondary outcomes will be biopsychosocial factors presents in the chronic musculoskeletal pain condition. Costs due to chronic musculoskeletal pain will be also measured, and cost-effectiveness analysis from a societal perspective will performed. DISCUSSION: Our hypothesis is that internet-based pain education and exercise will be better than an online booklet in reducing pain and improving biopsychosocial outcomes in patients with chronic musculoskeletal pain. In addition, we believe that there will be good acceptance of patients for the internet-based intervention and that internet-based intervention will be more cost effective than the online booklet. TRIAL REGISTRATION: The study was prospectively registered at ClinicalTrials.gov ( NCT04274439 , registered 18 February 2020).

The contemporary management of nonspecific lower back pain.

Low back pain (LBP) is extremely common and causes an enormous burden on the society. This perspective article aims to provide an evidence-based summary in the field of LBP. More specifically, we aimed to present epidemiological data on cost, diagnosis, prognosis, prevention and interventions for patients with LBP. It is critical that both clinicians and policymakers follow best practices by using high-value care for patients with LBP. In addition, nonevidence-based procedures must be immediately abandoned. These actions are likely to reduce societal costs and will improve the quality of life of these patients.