Health professionals and students encounter multi-level barriers to implementing high-value osteoarthritis care: a multi-national study.

OBJECTIVE: Consistent evidence-practice gaps in osteoarthritis (OA) care are observed in primary care settings globally. Building workforce capacity to deliver high-value care requires a contemporary understanding of barriers to care delivery. We aimed to explore barriers to OA care delivery among clinicians and students. DESIGN: A cross-sectional, multinational study sampling clinicians (physiotherapists, primary care nurses, general practitioners (GPs), GP registrars; total possible denominator: n = 119,735) and final-year physiotherapy and medical students (denominator: n = 2,215) across Australia, New Zealand and Canada. Respondents answered a survey, aligned to contemporary implementation science domains, which measured barriers to OA care using categorical and free-text responses. RESULTS: 1886 clinicians and 1611 students responded. Items within the domains 'health system' and 'patient-related factors' represented the most applicable barriers experienced by clinicians (25-42% and 20-36%, respectively), whereas for students, 'knowledge and skills' and 'patient-related factors' (16-24% and 19-28%, respectively) were the most applicable domains. Meta-synthesis of qualitative data highlighted skills gaps in specific components of OA care (tailoring exercise, nutritional/overweight management and supporting positive behaviour change); assessment, measurement and monitoring; tailoring care; managing case complexity; and translating knowledge to practice (especially among students). Other barriers included general infrastructure limitations (particularly related to community facilities); patient-related factors (e.g., beliefs and compliance); workforce-related factors such as inconsistent care and a general knowledge gap in high-value care; and system and service-level factors relating to financing and time pressures, respectively. CONCLUSIONS: Clinicians and students encounter barriers to delivery of high-value OA care in clinical practice/training (micro-level); within service environments (meso-level); and within the health system (macro-level).

Radiographic measures of thoracic kyphosis in osteoporosis: Cobb and vertebral centroid angles.

OBJECTIVE: Several measures can quantify thoracic kyphosis from radiographs, yet their suitability for people with osteoporosis remains uncertain. The aim of this study was to examine the validity and reliability of the vertebral centroid and Cobb angles in people with osteoporosis. DESIGN AND PATIENTS: Lateral radiographs of the thoracic spine were captured in 31 elderly women with osteoporosis. Thoracic kyphosis was measured globally (T1-T12) and regionally (T4-T9) using Cobb and vertebral centroid angles. Multisegmental curvature was also measured by fitting polynomial functions to the thoracic curvature profile. Canonical and Pearson correlations were used to examine correspondence; agreement between measures was examined with linear regression. RESULTS: Moderate to high intra- and inter-rater reliability was achieved (SEM = 0.9-4.0 degrees ). Concurrent validity of the simple measures was established against multisegmental curvature (r = 0.88-0.98). Strong association was observed between the Cobb and centroid angles globally (r = 0.84) and regionally (r = 0.83). Correspondence between measures was moderate for the Cobb method r = 0.72), yet stronger for the centroid method (r = 0.80). The Cobb angle was 20% greater for regional measures due to the influence of endplate tilt. CONCLUSIONS: Regional Cobb and centroid angles are valid and reliable measures of thoracic kyphosis in people with osteoporosis. However, the Cobb angle is biased by endplate tilt, suggesting that the centroid angle is more appropriate for this population.

The vertebral fracture cascade in osteoporosis: a review of aetiopathogenesis.

Once an initial vertebral fracture is sustained, the risk of subsequent vertebral fracture increases significantly. This phenomenon has been termed the "vertebral fracture cascade". Mechanisms underlying this fracture cascade are inadequately understood, creating uncertainty in the clinical environment regarding prevention of further fractures. The cascade cannot be explained by low bone mass alone, suggesting that factors independent of this parameter contribute to its aetiopathogenesis. This review explores physiologic properties that may help to explain the vertebral fracture cascade. Differences in bone properties, including bone mineral density and bone quality, between individuals with and those without osteoporotic vertebral fractures are discussed. Evidence suggests that non-bone parameters differ between individuals with and those without osteoporotic vertebral fractures. Spinal properties, including vertebral macroarchitecture, intervertebral disc integrity, spinal curvature and spinal loading are compared in these groups of individuals. Cross-sectional studies also indicate that neurophysiologic properties, particularly trunk control and balance, are affected by the presence of a vertebral fracture. This review provides a synthesis of the literature to highlight the multi-factorial aetiopathogenesis of the vertebral fracture cascade. With a more comprehensive understanding of the mechanisms underlying this clinical problem, more effective preventative strategies may be developed to offset the fracture cascade.

Balance impairment is related to vertebral fracture rather than thoracic kyphosis in individuals with osteoporosis.

INTRODUCTION: Balance impairments have been identified in people with osteoporosis. Although an association between thoracic kyphosis and impaired balance has been reported, the specific role of vertebral fractures has not been considered. This study aimed to investigate the independent effects of osteoporotic vertebral fracture and thoracic kyphosis on balance characteristics in an osteoporotic population. METHODS: Twenty-two individuals with osteoporosis were divided into groups with (n=10) and without (n=12) radiologically diagnosed fracture, and into groups with low (n=11) and high (n=11) thoracic kyphosis. Force-plate-derived balance parameters were recorded during three static standing tasks of 70-s duration. Balance measures were compared between fracture and kyphosis groups, and significant differences were further explored through subgroup analyses, to tease out the relationships between confounded independent variables (fracture and kyphosis) and balance measures. RESULTS: In the anterior-posterior direction, the range and root mean square of shear forces (p=0.048 and p=0.032, respectively), and range of displacement of the centre of pressure (p=0.049) were greater in the fracture group. There were no differences between groups when comparison was based on the magnitude of thoracic kyphosis (all p>or=0.264). Analyses of subgroups supported these findings. DISCUSSION: Vertebral fracture but not thoracic kyphosis is associated with impaired balance characteristics in the osteoporosis population. This finding has important implications for fracture prevention and conservative management regimes.

Chlordiazepoxide effects on reactions to novelty and activity with and without prior drug experience.

Reactions to novelty, rearing and ambulation were observed in rats following saline or chlordiazepoxide injections either with or without prior drug experience. Drug suppression of the former two response was evident but there was no indication of prior drug experience being effective. However, experience appeared to negate the compound's depressant effect on ambulation shown by inexperienced subjects. It was concluded that inhibitory influences of chlordiazepoxide on reactions to novelty and rearing can not be ascribed to the aversive effects of a novel drug state.