Effectiveness of specific scapular therapeutic exercises in patients with shoulder pain: a systematic review with meta-analysis.

Background: Therapeutic exercise has been considered a useful tool to rehabilitate shoulder pain, namely through its influence on scapular dynamics. Accordingly, the effectiveness of scapular therapeutic exercise needs to be explored. The present study aims to evaluate the effectiveness of scapular therapeutic exercises in shoulder pain and to identify the most effective exercise type (focal or multijoint) and ways of delivering them (as dose and progression). Methods: Search was conducted at EMBASE, Cochrane Library, MEDLINE via PubMed, Web of Science, PEDro (Physiotherapy Evidence Database), and trial registration databases. The meta-analysis considered randomized controlled/crossover trials that compared the effect of scapular exercises against other types of intervention in the shoulder pain, shoulder function, scapular motion, and/or muscular activity. The risk of bias was assessed through the PEDro scale. Results: From the 8318 records identified, 8 (high to low risk of bias- scoring from 4 to 8 on the PEDro scale) were included. The overall data, before sensitivity analysis, indicated that the scapular therapeutic exercises are: a) more effective than comparators in improving shoulder function (standardized mean difference [SMD] = 0.52 [95% Cl: 0.05, 0.99], P = .03, I2 = 76%); and b) as effective as comparators in reducing shoulder pain (SMD = 0.32 [95% Cl: -0.09, 0.73], P = .13, I2 = 70%). Subgroup analysis revealed that scapular exercises are more effective in improving shoulder function when the program duration is equal to or higher than 6 weeks (SMD = 0.43 [95% Cl: 0.09, 0.76] P = .01, I2 = 21%) and/or when the maximum number of exercise repetitions per session is lower than 30 (SMD = 0.79 [95% Cl: 0.15, 1.42], P = .01, I2 = 77%). Only 1 study considered scapular motion as an outcome measure, revealing therapeutic exercise effectiveness to improve scapular range of motion. Conclusions: Intervention programs involving scapular therapeutic exercises are effective in improving shoulder function, presenting benefits when performed for 6 or more weeks and/or when used up to a maximum of 30 repetitions per exercise, per session.

Correction: Implementation of digital health in rural populations with chronic musculoskeletal conditions: A scoping review protocol.

[This corrects the article DOI: 10.1371/journal.pone.0291638.].

Scapular muscle dynamic stiffness of asymptomatic subjects and subjects with chronic shoulder pain, at rest and isometric contraction conditions.

Muscle stiffness had a crucial role in joint stability, particularly, at the shoulder complex. Although changes in upper trapezius muscle stiffness have been described for shoulder pain, contradictory findings have been obtained. Also, existing data regarding scapular muscles are, majorly, about trapezius. Myotonometry is a method used to assess stiffness; however, the reliability values of scapular muscle stiffness through this method have not been assessed in shoulder pain conditions. The present study aims to compare scapular muscles' stiffness (trapezius, serratus anterior, and levator scapulae) between subjects with and without chronic shoulder pain and to evaluate the related test-retest reliability. Twenty-two symptomatic and twenty-two asymptomatic subjects participated in a cross-sectional study. The dynamic muscular stiffness of scapular muscles, at rest and during an isometric contraction, was measured bilaterally with myotonometry, in two moments. The differences in bilateral averaged values between symptomatic and asymptomatic subjects and the effect of the group (group presenting pain in the dominant or non-dominant side, and asymptomatic group) and of the limb (unilateral painful or asymptomatic limb, and bilateral asymptomatic limbs) were investigated. Test-retest intra-rater reliability was determined. An effect of the group was observed at rest, for middle trapezius stiffness, and during contraction, for middle and lower trapezius stiffness. For middle trapezius, increased values were observed in the group presenting pain in non-dominant side comparing to both groups or to group presenting pain in dominant side. The intraclass correlation coefficient, majorly, ranged between 0.775 and 0.989. Participants with pain in the non-dominant side presented an increased middle trapezius' stiffness. Globally, high reliability was observed for scapular muscles dynamic stiffness.

Physiotherapists' barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice in patients at risk of recurrence of low back pain: a qualitative study.

BACKGROUND: Recurrences of low back pain (LBP) are frequent and associated with high levels of disability and medical costs. Regular exercise practice may be an effective strategy to prevent recurrences of LBP, however, the promotion of this behaviour by physiotherapists seems to be challenging. This study aims to explore physiotherapists' perceived barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice by patients at risk of recurrence of low back pain. METHODS: Two focus groups with primary healthcare physiotherapists were conducted, based on a semi-structured interview schedule informed by the Behaviour Change Wheel, including the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). All focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis, using a coding matrix based on the COM-B and TDF, was performed by two independent researchers. A third researcher was approached to settle disagreements. RESULTS: In total, 14 physiotherapists participated in the focus groups. The analysis revealed a total of 13 barriers (4 COM-B components and 7 TDF domains) and 23 facilitators (5 COM-B and 13 TDF) to physiotherapists' implementation of a behaviour change-informed exercise intervention. The most common barriers were the lack of skills and confidence to implement the proposed intervention. These were explained by the fact that it differs from the usual practice of most participants and requires the learning of new skills applied to their contexts. However, for those who had already implemented other similar interventions or whose rationale is aligned with the new intervention, there seemed to exist more positive determinants, such as potential benefits for physiotherapists and the profession, improvement of quality of care and willingness to change clinical practice. For others who did not previously succeed in implementing these types of interventions, more context-related barriers were mentioned, such as lack of time to implement the intervention, schedule incompatibilities and lack of material and human resources. CONCLUSIONS: This study identified modifiable barriers and facilitators to physiotherapists' implementation of a behaviour change-informed exercise intervention for patients at risk of recurrence of LBP in primary healthcare. The findings of this study will allow the systematic and theory-based development of a behaviour change-informed training programme, aimed at physiotherapists and supporting the successful implementation of the exercise intervention.

Minimal Intervention of Patient Education for Low Back Pain: A Systematic Review With Meta-analysis.

OBJECTIVE: To explore the effects of minimal intervention of patient education (MIPE) for reducing disability and pain intensity in patients with low back pain (LBP). DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials. LITERATURE SEARCH: We searched the MEDLINE, Embase, CENTRAL, CINAHL, and PsycINFO databases from inception to May 2023. STUDY SELECTION CRITERIA: Trials comparing MIPE, consisting of a single session of patient education, to no or other interventions in patients with LBP. DATA SYNTHESIS: Random effects meta-analysis was conducted where possible. A noninferiority margin of 5 points (0-100 scale) was considered for noninferiority hypotheses. We assessed risk of bias using the revised Cochrane risk-of-bias tool (RoB 2), and certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. RESULTS: A total of 21 trials were included. There were no differences between MIPE and no intervention for effects on disability and pain intensity. There was low-certainty evidence that MIPE had inferior effects on short-term disability (mean difference = 3.62; 95% CI: 0.85, 6.38; 15 trials; n = 3066; I2 = 75%) and pain intensity (mean difference = 9.43; 95% CI: 1.31, 17.56; 10 trials; n = 1394; I2 = 90%) than other interventions. No differences were found for subsequent time points. CONCLUSION: As an intervention delivered in isolation, and without tailoring (ie, one-size-fits-all intervention), MIPE on average did not provide benefits for reducing disability and pain intensity over no or other interventions. We encourage clinicians to consider using additional/other or more tailored treatments when helping people manage LBP. J Orthop Sports Phys Ther 2024;54(2):1-13. Epub 16 November 2023. doi:10.2519/jospt.2023.11865.

Implementation of digital health in rural populations with chronic musculoskeletal conditions: A scoping review protocol.

Musculoskeletal conditions are a major source of disability worldwide, and its burden have been rising in the last decades. Rural areas, in particular, are associated with higher prevalence of these conditions as well as higher levels of disability, which is likely related to other determinants that affect these communities. Although digital health has been identified as a potential solution to mitigate the impact of these determinants, it is also known that these populations may face barriers that limit the implementation of these interventions. Therefore, the aim of this scoping review is to comprehensively map the evidence regarding the implementation of digital health interventions in rural populations with chronic musculoskeletal conditions. We will include studies published from the year 2000; that report the use of digital interventions that promote prevention, treatment or monitoring of any chronic musculoskeletal condition or chronic pain from musculoskeletal origin, in patients that live in rural areas. This protocol follows the methodological framework for scoping reviews proposed by Arksey and O'Malley, as well as the Joana Briggs Institute (JBI) approach. We will conduct the search on Medline (PubMed), EMBASE, Web of Science and Scopus, as well as grey literature databases. Two independent reviewers will screen titles and abstracts followed by a full-text review to assess the eligibility of the articles. Data extracted will include the identification of the digital interventions used, barriers and enablers identified by the patients or healthcare providers, the patient-level outcomes measured, and the implementation strategies and outcomes reported. By mapping the evidence on the implementation of digital health interventions in rural communities with musculoskeletal conditions, this scoping review will enhance our understanding of their applicability in real-world settings.

Trajectories of physical function and quality of life in people with osteoarthritis: results from a 10-year population-based cohort.

OBJECTIVE: To identify long-term trajectories of physical function and health-related quality of life (HRQoL) among people with hip and/or knee osteoarthritis (HKOA) and the sociodemographic, lifestyle, and clinical factors associated with different trajectories. METHODS: Participants with HKOA from the EpiDoC study, a 10-year follow-up (2011-2021) population-based cohort, were considered. Sociodemographic, lifestyle, and clinical variables were collected at baseline in a structured interview and clinical appointment. Physical function and HRQoL were evaluated with the Health Assessment Questionnaire (HAQ) and EuroQoL, respectively, at baseline and the three follow-ups. Group-based trajectory modeling identified physical function and HRQoL trajectories. Multinomial logistic regression analyzed the associations between the covariates of interest and trajectory assignment (p < 0.05). RESULTS: We included 983 participants with HKOA. We identified three trajectories for each outcome: "consistently low disability" (32.0%), "slightly worsening moderate disability" (47.0%), and "consistently high disability" (21.0%) for physical function; "consistently high HRQoL" (18.3%), "consistently moderate HRQoL" (48.4%) and "consistently low HRQoL" (33.4%) for HRQoL. Age ≥ 75 years, female sex, multimorbidity, and high baseline clinical severity were associated with higher risk of assignment to poorer physical function and HRQoL trajectories. Participants with high education level and with regular physical activity had a lower risk of assignment to a poor trajectory. Unmanageable pain levels increased the risk of assignment to the "consistently moderate HRQoL" trajectory. CONCLUSION: Although the trajectories of physical function and HRQoL remained stable over 10 years, approximately 70% of people with HKOA maintained moderate or low physical function and HRQoL over this period. Modifiable risk factors like physical activity, multimorbidity and clinical severity were associated with poorer physical function and HRQoL trajectories. These risk factors may be considered in tailored healthcare interventions.

Differences in Trapezius Muscle H-Reflex between Asymptomatic Subjects and Symptomatic Shoulder Pain Subjects.

In chronic shoulder pain, adaptations in the nervous system such as in motoneuron excitability, could contribute to impairments in scapular muscles, perpetuation and recurrence of pain and reduced improvements during rehabilitation. The present cross-sectional study aims to compare trapezius neural excitability between symptomatic and asymptomatic subjects. In 12 participants with chronic shoulder pain (symptomatic group) and 12 without shoulder pain (asymptomatic group), the H reflex was evoked in all trapezius muscle parts, through C3/4 nerve stimulation, and the M-wave through accessory nerve stimulation. The current intensity to evoke the maximum H reflex, the latency and the maximum peak-to-peak amplitude of both the H reflex and M-wave, as well as the ratio between these two variables, were calculated. The percentage of responses was considered. Overall, M-waves were elicited in most participants, while the H reflex was elicited only in 58-75% or in 42-58% of the asymptomatic and symptomatic participants, respectively. A comparison between groups revealed that the symptomatic group presented a smaller maximum H reflex as a percentage of M-wave from upper trapezius and longer maximal H reflex latency from the lower trapezius (p < 0.05). Subjects with chronic shoulder pain present changes in trapezius H reflex parameters, highlighting the need to consider trapezius neuromuscular control in these individuals' rehabilitation.

The European Portuguese Version of the Composite Physical Function Scale: Cross-Cultural Adaptation and Validation in Community-Dwelling Older Adults.

This study aims to perform the cross-cultural adaptation to European Portuguese of the Composite Physical Function Scale and to assess its validity and reliability in a sample of community-dwelling older adults. The scale was translated into European Portuguese, back translated, and piloted in a sample of 16 representative individuals. Its validity and reliability were tested in an independent sample of 114 community-dwelling older adults (52 were tested twice to assess test-retest reliability). The results showed that the scale had good internal consistency (α = .90), construct validity (ρ = .71) and measurement error (78.8% agreement), and excellent test-retest reliability (κ = .98). However, a ceiling effect was found as 28% of the participants achieved the highest possible score. Although the scale has good measurement properties, the presence of ceiling effects is indicative that this tool is not able to distinguish higher levels of intrinsic capacity within community-dwelling older adults.

The influence of shoulder position during multi-joint exercises in the relative scapular muscles activity in symptomatic and asymptomatic conditions.

BACKGROUND: Scapular muscles changes, as increased upper trapezius activity and decreased middle and lower trapezius and serratus anterior muscle activity, have been demonstrated in shoulder pain specific or non-specific conditions. Shoulder external rotation exercises have been recommended to improve scapular activity in shoulder pain. OBJECTIVE: To evaluate the relative scapular muscles activity during multi-joint exercises combining shoulder external rotation, trunk rotation and scapular squeeze. METHODS: Forty-one participants with and without shoulder pain were assessed in a cross-sectional study. They performed isometric multi-joint exercises at 0∘ and 90∘ of shoulder abduction with and without support. The relative activity of upper, middle, and lower trapezius and serratus anterior (upper/middle and lower portions) was measured through electromyography. The scapular muscular balance was assessed by the ratio between relative activity of the upper trapezius and the other muscles. RESULTS: Both groups presented similar results. The exercise at 90∘ abduction led to increased relative muscle activity against maximal voluntary contraction in both groups for upper trapezius (with support: 4% MVIC, p= 0.001 or 15% MVIC, p< 0.0001; and without support: 11% MVIC, p< 0.0001 or 13%, p< 0.0001, for asymptomatic and symptomatic group, respectively) and lower trapezius (with support: 66% MVIC, p< 0.0001 or 62% MVIC, p< 0.0001, for asymptomatic and symptomatic group.

Prevalence of and factors associated with unmanageable pain levels in people with knee or hip osteoarthritis: a cross-sectional population-based study.

BACKGROUND: Pain due to knee and / or hip osteoarthritis (HKOA) is the most common symptom for seeking healthcare. Pain interferes on daily activities, social and occupational participation in people with HKOA. The goal of this study is to estimate the prevalence of unmanageable pain levels (UPL) among people with HKOA), characterize this population and identify factors associated with UPL, and compare therapeutic strategies used by people with UPL versus manageable pain levels (MPL). METHODS: We analysed data from the EpiReumaPt study (n = 10,661), that included a representative sample of the Portuguese population. Among these, 1081 participants had a validated diagnosis of HKOA by a rheumatologist.. Sociodemographic, lifestyle and health-related data were collected in a structured interview. Pain intensity (NPRS) data were collected in a medical appointment. Painmedication (last month), physiotherapy and surgery were considered as therapies for pain management. UPL was defined as a mean pain intensity in the previous week of ≥5 points on 11-point numeric pain rating scale. The factors associated with UPL were analyzed with logistic regression (p < 0.05, 95%CI). The effect of unmanageable pain levels was assessed by the HOOS/KOOS activities of daily living and quality of life subscales. Symptoms of anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). Analysis was completed with linear and logistic regression. All analysis were weighted. RESULTS: The estimated prevalence of UPL among people with HKOA was 68.8%. UPL was associated with being female (odds ratio (OR) = 2.36, p < 0.001), being overweight (OR = 1.84, p = 0.035) or obese (OR = 2.26, p = 0.006), and having multimorbidity (OR = 2.08, p = 0.002). People with UPL reported worse performance in activities of daily living and lower quality of life (ß = - 21.28, p < 0.001 and ß = - 21.19, p < 0.001, respectively) than people with MPL. People with UPL consumed more NSAIDs (22.0%, p = 0.003), opioids (4.8%, p = 0.008), paracetamol (2.7%, p = 0.033), and overall analgesics (7.3%, p = 0.013) than people with MPL. A higher proportion of people with UPL underwent physiotherapy (17.5%, p = 0.002) than people with MPL. CONCLUSION: Two-thirds of people with HKOA in Portugal have poor management of their pain levels. Clinical and lifestyle factors, that are highly presented in individuals with HKOA, are associated with unmanageable pain. Our results highlighting the need for further research and implementation of effective interventions to improve pain, function and quality of life in people with HKOA.

Association of physical activity with physical function and quality of life in people with hip and knee osteoarthritis: longitudinal analysis of a population-based cohort.

Hip and knee osteoarthritis (HKOA) is a chronic disease characterized by joint pain that leads to reduced physical function and health-related quality of life (HRQoL). At present, no cure is available. Clinical trials indicate that people with HKOA benefit from physical activity in several health-related outcomes. However, few studies have evaluated the long-term positive effect of regular physical activity. This study analyzed participants with HKOA from a nationwide population-based cohort (EpiDoC Cohort) to assess the impact of physical activity on patients' physical function and HRQoL over a long-term follow-up. The regular weekly frequency of intentional physical activity was self-reported as non-frequent (0 times/week), frequent (1-2 times/week), or very frequent (≥ 3 times/week). This study followed 1086 participants over a mean period of 4.7 ± 3.4 years, during which 6.3% and 14.9% of participants reported frequent and very frequent physical activity, respectively. Using linear mixed models, we found that frequent (ß = - 0.101 [- 0.187, - 0.016]; ß = 0.039 [- 0.002, 0.080]) and very frequent physical activity (ß = - 0.061 [- 0.118, - 0.004]; ß = 0.057 [0.029, 0.084]) were associated with improved physical function and HRQoL over time, respectively, when compared with non-frequent exercise, adjusting for years to baseline, sex, age, years of education, body mass index, multimorbidity, hospitalizations, clinical severity, and unmanageable pain levels. These findings raise awareness of the importance of maintaining exercise/physical activity long term to optimize HRQoL and physical function. Further studies must address barriers and facilitators to improve the adoption of regular physical activity among citizens with HKOA.

Models of care for low back pain patients in primary healthcare: a scoping review protocol.

INTRODUCTION: Low back pain (LBP) is the most prevalent musculoskeletal condition worldwide and it is responsible for high healthcare costs and resources consumption. It represents a challenge for primary care services that struggle to implement evidence-based practice. Models of care (MoCs) are arising as effective solutions to overcome this problem, leading to better health outcomes. Although there is growing evidence regarding MoCs for the management of LBP patients, an analysis of the existing body of evidence has not yet been carried out. Therefore, this scoping review aims to identify and map the current evidence about the implementation of MoCs for LBP in primary healthcare. Findings from this study will inform policy makers, health professionals and researchers about their characteristics and outcomes, guiding future research and best practice models. METHODS AND ANALYSIS: This protocol will follow the Joanna Briggs Institute methodological guidelines for scoping reviews. Studies that implemented an MoC for LBP patients in primary healthcare will be included. Searches will be conducted on PubMed, EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science, grey literature databases and relevant organisations websites. This review will consider records from 2000, written in English, Portuguese or Spanish. Two researchers will independently screen all citations and full-text articles and abstract data. Data extracted will include the identification of the MoC, key elements of the intervention, organisational components, context-specific factors and patient-related, system-related and implementation-related outcomes. ETHICS AND DISSEMINATION: As a secondary analysis, this study does not require ethical approval. It will provide a comprehensive understanding on existing MoCs for LBP, outcomes and context-related challenges that may influence implementation in primary healthcare, which is meaningful knowledge to inform future research in this field. Findings will be disseminated through research papers in peer-reviewed journals, presentations at relevant conferences and documentation for professional organisations and stakeholders.

Scapular Dynamic Muscular Stiffness Assessed through Myotonometry: A Narrative Review.

Several tools have been used to assess muscular stiffness. Myotonometry stands out as an accessible, handheld, and easy to use tool. The purpose of this review was to summarize the psychometric properties and methodological considerations of myotonometry and its applicability in assessing scapular muscles. Myotonometry seems to be a reliable method to assess several muscles stiffness, as trapezius. This method has been demonstrated fair to moderate correlation with passive stiffness measured by shear wave elastography for several muscles, as well as with level of muscle contraction, pinch and muscle strength, Action Research Arm Test score and muscle or subcutaneous thickness. Myotonometry can detect scapular muscles stiffness differences between pre- and post-intervention in painful conditions and, sometimes, between symptomatic and asymptomatic subjects.

Factors Associated With Clinical and Radiographic Severity in People With Osteoarthritis: A Cross-Sectional Population-Based Study.

Background: Hip/knee osteoarthritis (HKOA) is a leading cause of disability and imposes a major socioeconomic burden. The aim of this study is to estimate the prevalence of HKOA in Portugal, characterised the clinical severity of HKOA in the population, and identified sociodemographic, lifestyle, and clinical factors associated with higher clinical and radiographic severity. Methods: Participants with a diagnosis of HKOA from the EpiReumaPt study (2011-2013) were included (n = 1,087). Hip/knee osteoarthritis diagnosis was made through a structured evaluation by rheumatologists according to American College of Rheumatology criteria. Clinical severity was classified based on Hip Disability and Osteoarthritis Outcome Scale (HOOS) and Knee Injury and Osteoarthritis Outcome Scale (KOOS) score tertiles. Radiographic severity was classified based on the Kellgren-Lawrence grades as mild, moderate, or severe. Sociodemographic lifestyle and clinical variables, including the presence of anxiety and depression symptoms, were analysed. Factors associated with higher clinical and radiographic severity were identified using ordinal logistic regression models. Results: Hip/knee osteoarthritis diagnosis was present in 14.1% of the Portuguese population [12.4% with knee osteoarthritis (OA) and 2.9% with hip OA]. Clinical severity was similar between people with hip (HOOS = 55.79 ± 20.88) and knee (KOOS = 55.33 ± 20.641) OA. People in the high HOOS/KOOS tertile tended to be older (64.39 ± 0.70 years), female (75.2%), overweight (39.0%) or obese (45.9%), and had multimorbidity (86.1%). Factors significantly associated with higher clinical severity tertile were age [55-64 years: odds ratio (OR) = 3.18; 65-74 years: OR = 3.25; ≥75 years: OR = 4.24], female sex (OR = 1.60), multimorbidity (OR = 1.75), being overweight (OR = 2.01) or obese (OR = 2.82), and having anxiety symptoms (OR = 1.83). Years of education was inversely associated with higher clinical severity. Factors significantly associated with higher radiographic severity were age (65-74 years: OR = 3.59; ≥75 years: OR = 3.05) and being in the high HOOS/KOOS tertile (OR = 4.91). Being a female and live in Lisbon or in the Centre region were inversely associated with the higher radiographic severity. Conclusion: Hip/knee osteoarthritis is present in ~1.1 million of Portuguese people. Age, educational level, and obesity are independently associated with HKOA clinical severity, whereas age, sex, geographic location, and clinical severity are independently associated with radiographic severity.

Driving factors for the utilisation of healthcare services by people with osteoarthritis in Portugal: results from a nationwide population-based study.

BACKGROUND: Worldwide, the current management of knee osteoarthritis appears heterogeneous, high-cost and often not based on current best evidence. The absence of epidemiological data regarding the utilisation of healthcare services may conceal the need for improvements in the management of osteoarthritis. The aim of this study is to explore the profiles of healthcare services utilisation by people with knee osteoarthritis, and to analyse their determinants, according to Andersen's behavioural model. METHODS: We analysed a sample of 978 participants diagnosed with knee osteoarthritis from the population-based study EpiReumaPt, in Portugal. Data was collected with a structured interview, and the diagnosis of knee osteoarthritis was validated by a rheumatologist team. With the Two-step Cluster procedure, we primarily identified different profiles of healthcare utilisation according to the services most used by patients with knee osteoarthritis. Secondly, we analysed the determinants of each profile, using multinomial logistic regression, according to the predisposing characteristics, enabling factors and need variables. RESULTS: In our sample, a high proportion of participants are overweight or obese (82,6%, n = 748) and physically inactive (20,6%, n = 201) and a small proportion had physiotherapy management (14,4%, n = 141). We identified three profiles of healthcare utilisation: "HighUsers"; "GPUsers"; "LowUsers". "HighUsers" represents more than 35% of the sample, and are also the participants with higher utilisation of medical appointments. "GPUsers" represent the participants with higher utilisation of general practitioner appointments. Within these profiles, age and geographic location - indicated as predisposing characteristics; employment status and healthcare insurance - as enabling factors; number of comorbidities, physical function, health-related quality of life, anxiety and physical exercise - as need variables, showed associations (p < 0,05) with the higher utilisation of healthcare services profiles. CONCLUSIONS: Healthcare utilisation by people with knee osteoarthritis is not driven only by clinical needs. The predisposing characteristics and enabling factors associated with healthcare utilisation reveal inequities in the access to healthcare and variability in the management of people with knee osteoarthritis. Research and implementation of whole-system strategies to improve equity in the access and quality of care are paramount in order to diminish the impact of osteoarthritis at individual-, societal- and economic-level.

Models of care for patients with knee osteoarthritis in primary healthcare: a scoping review protocol.

INTRODUCTION: Knee osteoarthritis (OA) is a prevalent condition with associated high disability and healthcare costs. Evidence of major gaps in the implementation of evidence-based interventions in people with knee OA led several healthcare systems to implement models of care (MoCs) in order to improve knowledge translation and guaranty their economic sustainability. Nevertheless, there are few studies that analyse the existing body of evidence of MoCs for patients with knee OA in primary healthcare settings. Therefore, we aim to identify MoCs developed for patients with knee OA implemented in primary healthcare and, analyse their core components and outcomes. This scoping review will create knowledge about the components and outcomes of these MoCs which, in the future, will facilitate their transferability to practice. METHODS AND ANALYSIS: We will include studies that developed and implemented an MoC for people with knee OA in primary healthcare. We will use the PCC mnemonic, being 'Population'-people with Knee OA, 'Concept'-the MoCs and 'Context'-the primary healthcare setting. We will conduct the search on PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, Web of Science Core Collection, as well as grey literature databases and relevant institutions and organisations websites, for articles published after 2000. Two independent reviewers will screen titles and abstracts followed by a full-text review to assess papers regarding their eligibility. We will evaluate the methodological quality of the included studies with the Mixed Methods Appraisal tool and apply a data abstraction form to describe and interpret the evidence. ETHICS AND DISSEMINATION: As a secondary analysis, this scoping review does not require ethical approval. Findings will be published in peer-review journal, presented in scientific conferences and as a summary through primary healthcare units.

Self-Reported Variables as Determinants of Upper Limb Musculoskeletal Symptoms in Assembly Line Workers.

BACKGROUND: Assembly lines work is frequently associated to work-related upper limb musculoskeletal disorders. The related disability and absenteeism make it important to implement efficient health surveillance systems. The main objective of this study was to identify self-reported variables that can determine work-related upper limb musculoskeletal symptoms-discomfort/pain-during a 6-month follow-up. METHODS: This was a prospective study with a 6-month follow-up period, performed in an assembly line. Upper limb musculoskeletal discomfort/pain was assessed through the presence of self-reported symptoms. Uni- and multivariate logistic regression analyses were used to evaluate which self-reported variables were associated to upper limb symptoms after 6 months at the present and to upper limbs symptoms in the past month. RESULTS: Of the 200 workers at baseline, 145 replied to the survey after 6 months. For both outcomes, "having upper limb symptoms during the previous 6 months" and "education" were possible predictors. CONCLUSION: Our results suggest that having previous upper limb symptoms was related to its maintenance after 6 months, sustaining it as a specific determinant. It can be a hypothesis that this population had mainly workers with chronic symptoms, although our results give only limited support to self-reported indicators as determinants for upper limb symptoms. Nevertheless, the development of an efficient health surveillance system for high demanding jobs should implicate self-reported indicators, but also clinical and work conditions assessment should be accounted on the future.

Prognostic indicators for poor outcomes in low back pain patients consulted in primary care.

BACKGROUND: Non-specific low back pain (NSLBP) is the most prevalent musculoskeletal condition in western countries and is associated with persistent disability and high consumption of health care resources. NSLBP patients first seek primary health care services but the outcomes are often uncertain. This study aimed to examine the clinical course of the outcomes and to identify prognostic indicators for poor outcomes in NSLBP patients who consulted primary care. METHODS: A prospective cohort study of 115 patients seeking treatment for NSLBP in primary care was conducted. Participants were consecutively recruited by their General Practitioners (GPs) and then assessed at baseline and 2 and 6 months later. Baseline assessment included socio-demographic and clinical data, psychosocial factors, pain, disability, and health related quality of life (HRQoL). Pain, disability, HRQoL and global perception of change were also assessed at 2 and 6-months' follow-up. In addition, information regarding the GP' practice was collected. Poor outcomes were determined according to the cut-off point used to define a persistent disabling condition and the minimal important change established for disability, pain and for global perception of change. The relationship between variables on baseline and poor outcomes was modulated through binary logistic regression analysis. The significance of associations was evaluated at ≤ 0.05 p-value with 95% confidence intervals (CI) and adjusted odds ratios (AOR). RESULTS: 110 (94.8%) and 104 (89.7%) participants completed the follow-up assessment at 2 and 6 months, respectively. The mean age (±SD) was 48.06 ± 11.41, with 53.9%, (N = 62) reporting an acute presentation of NSLBP. Six months after GP consultation, 53.8% (N = 56) of the participants reported a persistent disabling condition. An "LBP episode of less than 12 weeks" [AOR: 0.26; 95% CI (0.10, 0.65); AOR: 0.34; 95% CI (0.14, 0.81); AOR: 0.21; 95% CI (0.09, 0.53)],"maladaptive psychosocial factors" [AOR: 2.06; 95% CI (1.40, 3.04); AOR: 1.82; 95% CI (1.27, 2.59); AOR: 1.72; 95% CI (1.20, 2.47)] were significantly associated with poor outcomes on disability, pain and global perception of change, respectively. Besides these factors, being employed reduces the chances of poor outcomes on disability [AOR 0.31; 95% CI (0.11, 0.92)]. CONCLUSIONS: A large proportion of LBP patients seeking primary health care reported poor outcomes 6 months after GP consultation. Patients who report chronic LBP, maladaptive psychosocial factors and are unemployed have a significant increase in the risk of poor outcome. These findings suggest the need of implementing effective models of care able to provide early screening and appropriate treatment to those at greatest risk of a poor outcome. TRIAL REGISTRATION: Current Controlled Trials NCT04046874 (August 6, 2019). Retrospectively registered.