Network meta-analysis for comparative effectiveness of treatments for chronic low back pain disorders: systematic review protocol.

INTRODUCTION: Chronic low back pain disorders (CLBDs) present a substantial societal burden; however, optimal treatment remains debated. To date, pairwise and network meta-analyses have evaluated individual treatment modes, yet a comparison of a wide range of common treatments is required to evaluate their relative effectiveness. Using network meta-analysis, we aim to evaluate the effectiveness of treatments (acupuncture, education or advice, electrophysical agents, exercise, manual therapies/manipulation, massage, the McKenzie method, pharmacotherapy, psychological therapies, surgery, epidural injections, percutaneous treatments, traction, physical therapy, multidisciplinary pain management, placebo, 'usual care' and/or no treatment) on pain intensity, disability and/or mental health in patients with CLBDs. METHODS AND ANALYSIS: Six electronic databases and reference lists of 285 prior systematic reviews were searched. Eligible studies will be randomised controlled/clinical trials (including cross-over and cluster designs) that examine individual treatments or treatment combinations in adult patients with CLBDs. Studies must be published in English, German or Chinese as a full-journal publication in a peer-reviewed journal. A narrative approach will be used to synthesise and report qualitative and quantitative data, and, where feasible, network meta-analyses will be performed. Reporting of the review will be informed by Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidance, including the network meta-analysis extension (PRISMA-NMA). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for network meta-analysis will be implemented for assessing the quality of the findings. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review of the published data. Findings will be disseminated via peer-reviewed publication. PROSPERO REGISTRATION NUMBER: PROSPERO registration number CRD42020182039.

An exploration of role expectations of the clinical prosthetist.

BACKGROUND: The role of the clinical prosthetist in healthcare has evolved substantially, and it is likely that expectations of the role have changed in recent times. Organisational Role Theory provides a framework for considering the expectations and behaviours of health professionals regarding their functions and roles. OBJECTIVES: The main objective of this study is to explore stakeholder consensus in role expectations of the clinical prosthetist in an Australian healthcare setting. STUDY DESIGN: Cross-sectional survey. METHODS: The Prosthetist Role Expectations Scale was used to measure expectations and views of the roles of clinical prosthetists. The Prosthetist Role Expectations Scale has 72 items that form 11 subscales that describe prosthetist behaviour. It was distributed to six key stakeholder groups which included: prosthetists, prosthetic technicians, physiotherapists, medical rehabilitation specialists, orthotists and clients with limb loss. RESULTS: Of the 1064 surveys distributed, 275 were returned. An additional 35 electronic responses were received, resulting in 299 complete data sets. A high level of consensus across the different stakeholder groups was found for 10 of the 11 subscales. In contrast, there were significant differences between groups for the 'Independent Prescription' subscale (p ⩽ .05). Differences in expectations, as noted by individual Prosthetist Role Expectations Scale subscale items (7 of 72) may indicate that stakeholders perceive a prosthetist's role differently in select areas. CONCLUSION: There was broad agreement in expectations from stakeholders regarding the role of prosthetists in interdisciplinary functioning, research and communication related to prosthetic device provision and function. There were more varied expectations regarding prescription decisions, referral practices and clinician-client communication regarding emotional issues. CLINICAL RELEVANCE: It is important to understand the expectations that stakeholder groups have regarding the clinical prosthetist role in healthcare settings. Such information can guide health professional education and interprofessional practice and may reduce interpersonal and interprofessional conflict.

Boxing for Parkinson's Disease: Has Implementation Accelerated Beyond Current Evidence?

Background: Exercise and physical activity are argued to promote neural plasticity in Parkinson's disease (PD), with potential to slow disease progression. Boxing for PD is rapidly growing in popularity. Objectives: (i) To evaluate evidence on benefits and risks of boxing exercises for people living with PD and (ii) to appraise websites for evidence of global implementation of this intervention. Data Sources: We searched AMED, CINAHL, Cochrane, EMBASE, EMCARE, Health and Medical Collection via ProQuest, MEDLINE, and PEDro electronic databases for the research literature. Websites were also searched for evidence of successful implementation of boxing for PD. Study Selection: Published research and websites were considered if they reported data on adults with PD and boxing as an intervention. Data Extraction: For the literature review, two reviewers independently extracted data on study characteristics and intervention content. Risk of bias was assessed with the PEDro scale and Joanna Briggs Checklist. We conducted a quality appraisal of websites using the QUality Evaluation Scoring Tool (QUEST). Data Synthesis: Two studies, with a total of 37 participants, met the review eligibility criteria for the literature review. Risk of bias was low in these trials. Balance confidence, mobility, and quality of life were reported to improve with community-based boxing training programs delivered in 24-36 sessions over 12 weeks. PD medications were not always documented and some elements of the boxing interventions were incompletely reported against the CERT (Consensus on Exercise Reporting Template). Nine websites advocating boxing programs for PD were also evaluated. The QUEST analysis showed low-level quality, and little scientific evidence verifying findings, despite positive reports. Limitations: In the published literature, findings were limited due to the small number of included studies and participants. Websites were numerous yet often lacked verifiable data. Conclusions: Despite the recent growth in the popularity of boxing for PD and some positive findings, there is limited evidence of efficacy. Risks and disease-specific modifications have not been reported. Safety guidelines and health professional training are key considerations for implementation.

The association between pregnancy, pelvic girdle pain and health-related quality of life - a comparison of two instruments.

BACKGROUND: The main purposes in this cross-sectional study were to study the impact of pregnancy and pelvic girdle pain (PGP) on health related quality of life (HRQoL), by comparing the scores on different domains of two HRQoL instruments in pregnant women with population norms as well as in women with severe and less severe PGP. Further, to explore the association between PGP and HRQoL and whether the two instruments differ in the way they assess the influence of PGP on HRQoL. METHODS: Pregnant women in gestation week 30 completed questionnaires containing the Short Form Health Survey (SF-36) and the Nottingham Health Profile (NHP). Additional variables, self-reported PGP, pain location in the pelvis and response on clinical tests were also collected. HRQoL scores were compared with expected age adjusted mean scores and comparisons between groups with different severity of PGP were made, using Mann-Whitney U, t-tests and Hodges-Lehman method. RESULTS: Two hundred eighty-three pregnant women, mean age 31.3 (SD 4.2) years, participated. We found statistical significant differences in all domains of both HRQoL instruments in late pregnancy compared to the expected age-adjusted means of the reference populations (p ≤ 0.003) except for Social isolation (p = 0.775). Women with PGP had lower HRQoL than women without, and the most affected women scored lowest. SF-36 detected a deficit in Social Function compared to norms whereas the NHP showed no evidence of Social Isolation. CONCLUSIONS: Both instruments revealed changes in HRQoL in pregnant women compared with population norms. Pregnancy itself influences HRQoL and having PGP gave an additional impact. The consistency of the correlations between SF-36 and NHP domains across the sub-groups found in this study suggests convergent validity across levels of impairment. The results in social domains vary between SF-36 and NHP in pregnant women and might be due to the basic design (construction) of the tools.

Association between hyper-pronated foot and the degree of severity of disability in patients with non-specific low back pain.

BACKGROUND: It has been established that Hyper-pronation of the foot may lead to postural changes in the lower limbs, with a resultant pelvic ante-version, and a subsequent risk of development of low back pain. However, the association between the presence of a hyper-pronated foot and the severity of disability in low back pain is currently not known. OBJECTIVES: The purpose of this study was to examine whether the presence of a hyper-pronated foot has any impact on the degree of severity of disability (functional status) in patients with non-specific low back pain. METHODS: An observational study was conducted in an outpatient setting, where patients diagnosed as having non-specific low back pain were included. The degree of severity of disability was measured using the Modified Oswestry Low Back Pain Disability Questionnaire, and the foot hyper-pronation was assessed with the execution of the Navicular Drop test. Descriptive statistics and Linear regression analyses were conducted. RESULTS: Of the 71 patients included, 14 demonstrated having a unilateral hyper-pronation of the foot. The mean scores for the functional status and hyper-pronation of the foot were 37.15 (SD = 10.40) and 6.06 (SD = 3.42) respectively. An association was not found between the severity of disability and the presence of foot hyper-pronation (B = .87, p = .78). CONCLUSIONS: Hyper-pronation of the foot could lead to the development of non-specific low back pain, but the degree of severity of the disability is not influenced by the presence of a hyper-pronated foot. The alterations in lower limb mechanics leading to back pain are a complex issue, and thus needs further research.

Short-term effects of mobilisation with movement in patients with post-traumatic stiffness of the knee joint.

BACKGROUND: Mobilisation with movement treatment techniques have been used to increase the range of motion following pathologies associated with shoulder, elbow and ankle joints. Lack of posterior tibial glide and reflex muscle inhibition are common physical impairments in individuals with post-traumatic stiffness of the knee joint. Current evidence is lacking for the benefits of mobilisation with movement treatment techniques for the knee joint disorders. OBJECTIVE: The purpose of this study was to investigate the short-term effects of mobilisation with movement techniques following post-traumatic stiffness of the knee joint. METHODS: Twenty consecutive patients with post-traumatic stiffness of the knee joint with a minimum available 80° knee flexion range of motion were included. One group pre-to-post-test study design was employed, in which the active knee flexion range of motion was used as an outcome measure. The mobilisation with movement treatment techniques was implemented with three sets of ten repetitions on each treatment occasion for a period of 3 days. RESULTS: The mobilisation with movement treatment techniques significantly improved the active knee flexion range of motion (p = 0.000) from pre-treatment to post-treatment. CONCLUSIONS: The findings from this study demonstrated immediate benefits in outcomes following mobilisation with movement treatment techniques in a cohort of patients with post-traumatic stiffness of the knee joint.

Do the key prognostic factors for non-specific neck pain have moderation effects? - A study protocol.

Neck pain is one of the common musculoskeletal conditions prevalent in the general population in Norway. Patients with neck pain, seek treatment from different health professionals such as general practitioners, physiotherapists, chiropractors and alternative medicine practitioners. The interventions for neck pain are typically provided in a primary care or specialised healthcare setting depending on the general practitioners' referral patterns. Clinicians are interested to know the various prognostic factors that can explain the recovery from neck pain. In order to know this, studies have explored and reported on a range of prognostic factors that contribute to the outcomes in patients with neck pain. This information is currently available only for neck pain following whiplash injury that has a traumatic origin. There is limited information on the role of prognostic factors specifically for non-specific neck pain without a traumatic episode. Moreover, there is a lack of data on whether there are interactions (moderation effects) between the prognostic factors. Therefore, we propose a hypothesis to elucidate whether the same set of prognostic factors found in neck pain associated with whiplash injuries are also identified in patients with neck pain without trauma. Additionally, we hypothesize that the association between a prognostic factor and the outcome variable (s) would be dependent on the third variable, thereby confirming the moderation effects. Clinicians could make informed decisions in the clinical management of neck pain with the knowledge of prognostic factors that explain the outcomes. It could also be used for the development of new interventions or for modifying the existing ones.

Psychological and Lifestyle Factors That Influence the Serial Reporting of Postconcussion-like Symptoms in a Non-concussed Population.

BACKGROUND: Symptoms related to concussion are generally nonspecific in nature, as they are also reported by non-concussed individuals. What is currently not known is whether the symptoms vary over time, and whether they are also influenced by a multitude of factors. OBJECTIVE: The aim of this study was to investigate the potential influence of psychological, lifestyle, and situational factors on the change in postconcussion-like symptoms reported over 7 consecutive days in a cohort of normal individuals. DESIGN: This was a longitudinal observational study. SETTING: The setting was a real-world context. PARTICIPANTS: A convenience sample of 180 non-concussed university students were enrolled. Of these, 110 participants provided data for the entire period of the study. METHODS: An experience-sampling methodology was used to document the symptoms reported over time. Stepwise multivariate linear mixed-effects modeling was performed to identify the predictors contributing to the serially reported symptoms. INDEPENDENT VARIABLES: Independent variables considered were gender, time of the day, location, primary activity, and type of interactant (person) of the participant, physical activity status, trouble sleeping, alcohol consumption, caffeine consumption, stress, anxiety, depression, mental and physical fatigue, and life stressors. MAIN OUTCOME MEASURES: The key outcome measures were the change in total symptom score (TSSchange) and symptom severity score (SSSchange) reported over 7 consecutive days. RESULTS: The predictors of location at the time of reporting, physical fatigue (estimate: -0.98, P < .001) and mental fatigue (estimate: -0.53, P < .001) contributed to the TSSchange. Post hoc analysis of the variable of location at the time of reporting revealed that participants reported increased TSSchange when they were at a café/restaurant compared to a flat/college or university. CONCLUSIONS: A number of factors within the context of daily life influenced the postconcussion-like symptoms reported over time. These findings indicate that clinicians need to be cautious when interpreting the serially assessed symptom scores to track the recovery profile of a concussed athlete to make decisions on return-to-play. Additional investigation is warranted to examine the change in symptom scores reported over time by concussed individuals, considering that this study was conducted in a nonconcussed cohort. LEVEL OF EVIDENCE: Not applicable.

Day-to-day variability of post-concussion-like symptoms reported over time by a non-concussed cohort.

PRIMARY OBJECTIVE: To explore the change (trend) in post-concussion-like symptoms reported over time. RESEARCH DESIGN: Longitudinal study. METHODS AND PROCEDURES: University students aged 18-30 years self-reported their symptoms experienced on a daily basis. Each participant was contacted via a text message each day during one of three pre-defined time zones to complete the Sport Concussion Assessment Tool 2 (SCAT2) post-concussion symptom scale on 7 consecutive days. MAIN OUTCOMES AND RESULTS: One hundred and ten (26 males and 84 females) students completed the study on all 7 days. Only two meaningful clusters emerged and comprised of a total of 105 participants. The primary cluster included 85 participants who showed a relatively stable pattern in their symptoms reported over time. Meanwhile, a second cluster comprised of 20 participants who demonstrated a decreasing trend in the reported symptom scores. CONCLUSIONS: The data indicated that non-concussed participants exhibited considerable individual variability in the symptom scores reported over time. However, some participants showed a systematic decreasing trend in their symptom scores reported over the 7 days. Caution must be exercised in interpreting the serial symptom scores that are obtained following a concussion, given that this study was conducted in a non-concussed cohort.

Smartphone and tablet apps for concussion road warriors (team clinicians): a systematic review for practical users.

BACKGROUND: Mobile technologies are steadily replacing traditional assessment approaches for the recognition and assessment of a sports concussion. Their ease of access, while facilitating the early identification of a concussion, also raises issues regarding the content of the applications (apps) and their suitability for different user groups. AIM: To locate and review apps that assist in the recognition and assessment of a sports concussion and to assess their content with respect to that of internationally accepted best-practice instruments. METHODS: A search of international app stores and of the web using key terms such as 'concussion', 'sports concussion' and variants was conducted. For those apps meeting the inclusion criteria, data were extracted on the platform, intended users and price. The content of each app was benchmarked to the Sport Concussion Assessment Tool 2 (SCAT2) and Pocket SCAT2 using a custom scoring scheme to generate a percentage compliance statistic. RESULTS: 18 of the 155 apps identified met the inclusion criteria. Almost all (16/18) were available on an iOS platform and only five required a payment to purchase. The apps were marketed for a wide range of intended users from medical professionals to the general public. The content of the apps varied from 0% to 100% compliance with the selected standard, and 'symptom evaluation' components demonstrated the highest level of compliance. CONCLUSIONS: The surge in availability of apps in an unregulated market raises concerns as to the appropriateness of their content for different groups of end users. The consolidation of best-practice concussion instruments now provides a framework to inform the development of future apps.

Big hits on the small screen: an evaluation of concussion-related videos on YouTube.

BACKGROUND: YouTube is one of the largest social networking websites, allowing users to upload and view video content that provides entertainment and conveys many messages, including those related to health conditions, such as concussion. However, little is known about the content of videos relating to concussion. OBJECTIVE: To identify and classify the content of concussion-related videos available on YouTube. STUDY DESIGN: An observational study using content analysis. METHODS: YouTube's video database was systematically searched using 10 search terms selected from MeSH and Google Adwords. The 100 videos with the largest view counts were chosen from the identified videos. These videos and their accompanying text were analysed for purpose, source and description of content by a panel of assessors who classified them into data-driven thematic categories. RESULTS: 434 videos met the inclusion criteria and the 100 videos with the largest view counts were chosen. The most common categories of the videos were the depiction of a sporting injury (37%) and news reports (25%). News and media organisations were the predominant source (51%) of concussion-related videos on YouTube, with very few being uploaded by professional or academic organisations. The median number of views per video was 26 191. CONCLUSIONS: Although a wide range of concussion-related videos were identified, there is a need for healthcare and educational organisations to explore YouTube as a medium for the dissemination of quality-controlled information on sports concussion.

Symptom response following acute bouts of exercise in concussed and non-concussed individuals - a systematic narrative review.

BACKGROUND: Athletes suspected of being concussed are frequently evaluated on the side-line for self-reported symptoms which guide subsequent management and return-to-play decisions. Concussion-like symptoms have been shown to be influenced by prior participation in physical activity; however, the potential contribution of acute exercise on symptoms is not well understood. OBJECTIVE: The purpose of this study was to systematically review the literature in order to further understand the acute effects of exercise on documented self-reported symptoms in both concussed and non-concussed individuals. DESIGN: Systematic narrative review. METHODS: Nine electronic databases were systematically searched using keywords and MeSH terms that included; self-reported symptoms, sports-related concussion, brain concussion, exercise and athletic injuries. In addition, an extensive search of the grey literature was conducted. RESULTS: Of the 785 articles retrieved, only five met the inclusion criteria comprising a total of 295 concussed and non-concussed participants. In general, the mean symptom scores increased from pre-exercise to post-exercise levels immediately following acute bouts of exercise in both concussed and non-concussed individuals. CONCLUSION: Although the symptom scores increased following exercise in both concussed and non-concussed participants, this increase was only maintained for a relatively short duration. Thus, the application to real world situation is still to be established.