Diagnostic utility of diagnostic investigations to identify neuropathic pain in low back-related leg pain: protocol for a systematic review.

INTRODUCTION: Neuropathic pain in low back-related leg pain has gained increasing interest in contemporary research. Identification of neuropathic pain in low back-related leg pain is essential to inform precision management. Diagnostic investigations are commonly used to identify neuropathic pain in low back-related leg pain; yet the diagnostic utility of these investigations is unknown. This systematic review aims to investigate the diagnostic utility of diagnostic investigations to identify neuropathic pain in low back-related leg pain. METHODS AND ANALYSIS: This protocol has been designed and reported in accordance with the Cochrane Handbook for Diagnostic Test Accuracy studies, Centre for Reviews and Dissemination and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols checklist, respectively. The search strategy will involve two independent reviewers searching electronic databases (CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro), key journals (Spine, The Clinical Journal of Pain, PAIN, European Journal of Pain, The Journal of Pain, Musculoskeletal Science and Practice) and grey literature (British National Bibliography for report literature, OpenGrey, EThOS) from inception to 31 July 2023 to identify studies. Studies evaluating the diagnostic accuracy of diagnostic investigation to identify neuropathic pain in patients with low back-related leg pain will be eligible, studies not written in English will be excluded. The reviewers will extract the data from included studies, assess risk of bias (Quality Assessment of Diagnostic Accuracy Studies 2) and determine confidence in findings (Grading of Recommendations, Assessment, Development and Evaluation guidelines). Methodological heterogeneity will be assessed to determine if a meta-analysis is possible. If pooling of data is not possible then a narrative synthesis will be done. ETHICS AND DISSEMINATION: Ethical approval is not required. Findings will be published in a peer-reviewed journal, presented at relevant conferences and shared with the Patient Partner Advisor Group at Western University, Canada. PROSPERO REGISTRATION NUMBER: CRD42023438222.

Developing an international competency and capability framework for advanced practice physiotherapy: a scoping review with narrative synthesis.

INTRODUCTION: The need to address increasing numbers of people seeking care, insufficient numbers of physicians, and providing high-value and sustainable care has contributed to changing physiotherapy practice across the world, often referred to as advanced practice physiotherapy. Currently, there is no internationally standardized competency and capability framework to support advanced practice physiotherapy. OBJECTIVES: This scoping review has two aims; 1) To identify and map out the competencies of advanced practice physiotherapy available in the literature. 2) To develop a competency and capability framework by mapping the competencies identified from the review. DESIGN: The Arksey and O'Malley framework and the PRISMA Scoping review methodology were used. Databases searched included CINAHL Plus, MEDLINE Ovid, PubMed, and Scopus. The competency and capability framework was developed through a narrative synthesis approach. RESULTS: Nineteen documents were included in the final review, with 13 grey literature (government reports, policy documents, thesis) and six research papers. Included publications came from the United Kingdom, Ireland, Australia, New Zealand, and Canada. The included documents covered predominantly musculoskeletal practice (n = 17). The others focused on cardiorespiratory care, incontinence and pelvic health. Through narrative synthesis, 27 competencies and capabilities were identified and grouped under seven domains. CONCLUSION: The synthesis of this scoping review provides the first competency and capability framework for advanced practice physiotherapy that integrates competencies and capabilities from five different countries. With the expansion of advanced practice physiotherapy, the framework developed from this review is the first step towards international recognition, standardization and consistency of education and training of practitioners. CONTRIBUTION OF THE PAPER.

Patient satisfaction with advanced physiotherapy practice internationally: Protocol for a systematic mixed studies review.

RATIONALE: Patient satisfaction is a complex construct consisting of human and system attributes. Patient satisfaction can afford insight into patient experience, itself a key component of evaluating healthcare quality. Internationally, advanced physiotherapy practice (APP) extends across clinical fields and is characterised as a higher level of practice with a high degree of autonomy and complex decision making. Patient satisfaction with APP appears positive. While evidence synthesis of patient satisfaction with APP exists, no systematic review has synthesised evidence across clinical fields. Therefore, the objectives of this systematic review are 1) to evaluate patient satisfaction with APP internationally, and 2) to evaluate human and system attributes of patient satisfaction with APP. MATERIALS AND METHODS: A systematic mixed studies review using a parallel-results convergent synthesis design will be conducted. Searches of Medline, Embase, Web of Science, CINAHL, Cochrane, PEDro and grey literature databases will be conducted from inception to 18/7/2023. Studies of APP (World Physiotherapy definition) whereby practitioners a) have advanced clinical and analytical skills that influence service improvement and provide clinical leadership, b) have post-registration masters level specialisation (or equivalence), c) deliver safe, competent care to patients with complex needs and d) may use particular occupational titles; that measure patient satisfaction across all clinical fields and countries will be included. Two reviewers will screen studies, extract data, assess methodological quality of included studies (mixed methods appraisal tool), and contribute to data synthesis. Quantitative data will undergo narrative synthesis (textual descriptions) and qualitative data thematic synthesis (analytical themes). Integration of data syntheses will inform discussion. IMPLICATIONS: This systematic review will provide insight into patient satisfaction with APP internationally, exploring attributes that influence satisfaction. This will aid design, implementation, or improvement of APP and facilitate the delivery of patient-centred, high-quality healthcare. Lastly, this review will inform future methodologically robust research investigating APP patient satisfaction and experience.

Developing a core competency and capability framework for advanced practice physiotherapy: A qualitative study.

INTRODUCTION: There is an urgent need to develop an international competency and capability framework to support standardization of education and roles in advanced practice physiotherapy (APP). This need arose due to the rapid growth of the APP model of care, implemented out of necessity in the absence of agreement as to the competencies and capabilities or formal education required for the roles. This study explores the views and perceptions of practitioners and key stakeholders on a draft competency and capability framework for advanced practice physiotherapists. OBJECTIVES: The purpose of this study was to: 1) gather feedback from key stakeholders (advanced practice physiotherapists, researchers, and leaders) on a draft competency and capability framework and 2) use that feedback to revise and improve the draft framework. DESIGN: Qualitative study using a series of four multi-national online focus groups. Thematic analysis was conducted according to Braun and Clarke. RESULTS: Sixteen participants from the United Kingdom, Ireland, Canada, Australia, and New Zealand participated in the study. Five themes were generated after data analysis: clinical expert, experienced communicator, strong leader, collaborator, and knowledge creator). A modified competency and capability framework was developed based on feedback from the focus groups and input from subject matter experts (SMEs). CONCLUSION: This study provides a modified core competency and capability framework comprising 24 competencies grouped under six domains. This study is a step toward international standardization of advanced practice physiotherapy based on a commonly agreed framework for the education and training of advanced practice physiotherapists.

A multi-site prospective, observational study of physiotherapist independent prescribing activity across musculoskeletal clinics in the United Kingdom.

OBJECTIVE: To establish how advanced practice physiotherapists in the UK working in the musculoskeletal specialty are utilising their independent non-medical prescribing skills. DESIGN: Multi-site, prospective, descriptive observational study. Ethics reference No: ERN_19-0994). METHOD: The study was conducted by seven advanced practitioners, across seven clinical sites representative of advanced musculoskeletal practice in the UK, between 1st October 2019-March 31, 2020. Advanced physiotherapy practitioner independent prescribers working in a variety of musculoskeletal specialty areas collected data across 5 contexts of musculoskeletal clinical service: first contact practice, primary care, community triage, secondary care orthopaedics, secondary care rheumatology and private practice. Quantitative data were analysed descriptively with qualitative data analysed/synthesised via thematic analysis. RESULTS: Prescribing activity data for n = 2470 patients were collected. Prescribing activity was highest for the treatment of nociceptive pain (51.3%) and inflammation (39.6%). Most prescribing activity occurred in the first 2-6 weeks (34.1%) following onset of condition. Medicines optimisation accounted for most of prescribing activity (18.1%), followed by over-the-counter medication recommendation (15.5%). De-prescribing accounted for 10.8% of all prescribing activity recorded. Qualitative data were synthesised into 4 themes: multimodal physiotherapeutic approach, joint decision making and patient choice, working with complexity, and legal and regulatory restriction. CONCLUSIONS: Physiotherapist independent prescribing was used within all health sectors in conjunction with advanced skills in musculoskeletal physiotherapy as part of a multimodal physiotherapeutic approach. Prescribing activity was dictated by the clinicians' clinical reasoning and use of joint decision-making. Prescribing activity for acute back and neuropathic radicular pain was limited secondary to recent reclassification of gabapentin and pregabalin.

Physical therapists demonstrate clinical behaviors consistent with established clinical practice guidelines in managing individuals following amputation.

BACKGROUND AND PURPOSE: Investigating physical therapy in amputation management offers insights into clinical practice. This study explores the self-reported clinical practice of physical therapists in amputation management and compares it to established clinical practice guidelines to determine whether physical therapists are delivering care that is considered recommended clinical practice. METHOD: An online survey of Australian physical therapists with limited or extensive experience in managing individuals following amputation. RESULTS: A total of 110 responses were received. The majority of Australian physical therapists (83%) reported their skills were adequate however, reported a lack of professional development opportunities. Physical therapists reported coordinating care with other health and medical professionals across all phases of care. They report providing comprehensive care in the following areas: residual limb management, pain management, falls prevention, education, counselling, psychological and peer support, and discharge planning. The majority of physical therapists were not aware if a comprehensive care plan was in place following a transition of care from a previous health service. DISCUSSION: Overall, physical therapists displayed clinical practice meeting the guidelines across most areas of amputation management. Future research into alternate data collection of clinical practice, and the development of physical therapy-specific clinical practice guidelines is needed.

Self-management of musculoskeletal (MSK) conditions: What is most useful to patients? Protocol for a mixed methods systematic review.

INTRODUCTION: Musculoskeletal (MSK) conditions are the leading cause of disability in the United Kingdom, leading to ever-growing waiting lists. Clinical guidelines highlight that most musculoskeletal conditions resolve in time and with little clinical input, and so supporting people to self-manage is recommended to optimise healthcare resources. Despite this, the term self-management remains ambiguous and to date no systematic review has evaluated if self-management is a suitable, acceptable, and effective intervention/strategy for managing all MSK conditions. METHODS AND ANALYSIS: This protocol is informed and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). An advanced convergent qualitative meta-integration mixed-studies design will be used. Using a comprehensive predetermined search strategy, databases, key journals and grey literature will be searched independently by two reviewers. The reviewers will independently assess eligibility, complete data extraction, and evaluate for risk of bias using the Mixed Methods Appraisal Tool (MMAT). The overall quality of included studies will be evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines. Data from mixed-methods studies will be transformed using a process of fractionation and analysed alongside the data extracted from the quantitative and qualitative studies, using descriptive analysis and thematic analysis, respectively. ETHICS AND DISSEMINATION: No research ethics are required for this systematic review since patient data will not be collected. The review will help to inform healthcare professionals and researchers on the most suitable, acceptable, and effective intervention/strategy for self-managing MSK conditions. Results of this review will be submitted for publication in a peer-reviewed journal and conference presentations.

The Concept of Pain Inventory (COPI): Assessing a Child's Concept of Pain.

OBJECTIVES: Clinical guidelines recommend that health care providers assist children to understand their experience of persistent pain, with pain science education a key component of clinical management in pediatric pain clinics. Currently, no tool exists to assess a child's concept of pain. The aim of this study was to develop such a tool and to evaluate its psychometric properties. METHODS: After a rigorous process to generate items, assess content validity, evaluate readability and understandability, and pretest items, a cohort of 124 children (aged 8 to 12 y) independently completed the measure on 2 occasions, along with additional measures of pain, function, and pain-related distress. RESULTS: The resulting unidimensional 14-item Concept of Pain Inventory (COPI) had acceptable internal consistency (α= 0.78) and moderate test-retest reliability (intraclass correlation coefficient (3,1) = 0.55; 95% CI, 0.37-0.68). Higher COPI scores reflect greater alignment with contemporary pain science. COPI scores were inversely correlated with pain intensity and functional disability, but unrelated to pain catastrophizing and pain-related fear. At 1 to 2 months' follow-up, baseline COPI scores were inversely correlated with clinical variables of functional disability and pain intensity. DISCUSSION: These results support the COPI as a brief, psychometrically sound tool to assess a child's concept of pain. Clinically, this tool may facilitate individualized pain science education to target identified conceptual "gaps" or misconceptions and to evaluate the effectiveness of pain science education in children. Further research examining its efficacy and impact is warranted.

Clinical indicators to identify neuropathic pain in low back related leg pain: a modified Delphi study.

BACKGROUND: Neuropathic pain (NP) is common in patients presenting with low back related leg pain. Accurate diagnosis of NP is fundamental to ensure appropriate intervention. In the absence of a clear gold standard, expert opinion provides a useful methodology to progress research and clinical practice. The aim of this study was to achieve expert consensus on a list of clinical indicators to identify NP in low back related leg pain. METHODS: A modified Delphi method consisting of three rounds was designed in accordance with the Conducting and Reporting Delphi Studies recommendations. Recruitment involved contacting experts directly and through expressions of interest on social media. Experts were identified using pre-defined eligibility criteria. Priori consensus criteria were defined for each round through descriptive statistics. Following completion of round 3 a list of clinical indicators that achieved consensus were generated. RESULTS: Thirty-eight participants were recruited across 11 countries. Thirty-five participants completed round 1 (92.1%), 32 (84.2%) round 2 and 30 (78.9%) round 3. Round 1 identified consensus (Kendall's W coefficient of concordance 0.456; p < 0.001) for 10 clinical indicators out of the original 14, and 9 additional indicators were added to round 2 following content analysis of qualitative data. Round 2 identified consensus (Kendall's W coefficient of concordance 0.749; p < 0.001) for 10 clinical indicators out of 19, and 1 additional indicator was added to round 3. Round 3 identified consensus for 8 indicators (Kendall's W coefficient of concordance 0.648; p < 0.001). Following completion of the third round, an expert derived consensus list of 8 items was generated. Two indicators; pain variously described a burning, electric shock like and/or shooting into leg and pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness), were found to have complete agreement amongst expert participants. CONCLUSIONS: Good agreement was found for the consensus derived list of 8 clinical indicators to identify NP in low back related leg pain. This list of indicators provide some indication of the criteria upon which clinicians can identify a NP component to low back related leg pain; further research is needed for stronger recommendations to be made.

Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back related leg pain: a systematic review and narrative synthesis.

BACKGROUND: Low back-related leg pain (LBLP) is a challenge for healthcare providers to manage. Neuropathic pain (NP) is highly prevalent in presentations of LBLP and an accurate diagnosis of NP in LBLP is essential to ensure appropriate intervention. In the absence of a gold standard, the objective of this systematic review was to evaluate the diagnostic utility of patient history, clinical examination and screening tool data for identifying NP in LBLP. METHODS: This systematic review is reported in line with PRISMA and followed a pre-defined and published protocol. CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro and PubMed databases, key journals and the grey literature were searched from inception to 31 July 2019. Eligible studies included any study design reporting primary diagnostic data on the diagnostic utility of patient history, clinical examination or screening tool data to identify NP in LBLP, in an adult population. Two independent reviewers searched information sources, assessed risk of bias (QUADAS-2) and used GRADE to assess overall quality of evidence. RESULTS: From 762 studies, 11 studies were included. Nine studies out of the 11 were at risk of bias. Moderate level evidence supports a cluster of eight signs (age, duration of disease, paroxysmal pain, pain worse in leg than back, typical dermatomal distribution, worse on coughing/sneezing/straining, finger to floor distance and paresis) for diagnosing lumbosacral nerve root compression, demonstrating moderate/high sensitivity (72%) and specificity (80%) values. Moderate level evidence supports the use of the StEP tool for diagnosing lumbar radicular pain, demonstrating high sensitivity (92%) and specificity (97%) values. CONCLUSIONS: Overall low-moderate level evidence supports the diagnostic utility of patient history, clinical examination and screening tool data to identify NP in LBLP. The weak evidence base is largely due to methodological flaws and indirectness regarding applicability of the included studies. The most promising diagnostic tools include a cluster of 8 patient history/clinical examination signs and the StEP tool. Low risk of bias and high level of evidence diagnostic utility studies are needed, in order for stronger recommendations to be made.

Independent prescribing by advanced physiotherapists for patients with low back pain in primary care: A feasibility trial with an embedded qualitative component.

BACKGROUND: Low back pain (LBP) is the most prevalent musculoskeletal condition. Guidelines advocate a multimodal approach, including prescription of medications. Advanced Physiotherapy Practitioners (APPs) are well placed to manage LBP. To date no trial has evaluated the efficacy of physiotherapist-prescribing for LBP. OBJECTIVES: To evaluate the feasibility, suitability and acceptability of assessing the effectiveness of physiotherapist-prescribing for LBP in primary care; informing the design of a future definitive stepped-wedged cluster trial (SWcRCT). METHODS: Mixed-methods, single-arm feasibility design with two components. 1) Trial component: participants with medium-risk LBP +/-leg pain were recruited across 3 sites. Outcome measures (primary outcome measures-Pain/RMDQ) were completed at baseline, 6 and 12 weeks Physical activity/sedentary behaviour were assessed over 7 days using accelerometery. A CONSORT diagram analysed recruitment/follow-up rates. Descriptive analysis evaluated procedure/floor-effects. 2) Embedded qualitative component: focus groups (n = 6) and semi-structured interviews (n = 3) evaluated the views/experiences of patients and APPs about feasibility/suitability/acceptability of the proposed trial. Thematic analysis synthesised the qualitative data. Findings were evaluated against a priori success criteria. RESULTS: n = 29 participants were recruited. 90% of success criteria were met. Loss to follow-up at 12 weeks (65.5%) did not satisfy success criteria. Primary and secondary outcome measures were suitable and acceptable with no floor effects. The addition of a sleep assessment tool was advised. Accelerometer use was acceptable with 100% adherence. APPs felt all patients presenting with non-specific LBP +/- leg pain and capture data representative of the full scope of physiotherapist independent prescribing should be included. Data collection methods were acceptable to APPs and patients. APPs advocated necessity for using research assistants owing to time limitations. CONCLUSIONS: Methods evaluated are feasible, suitable and acceptable for a definitive SWcRCT, with modification of eligibility criteria, and use of research assistants to overcome limited clinician capacity. A definitive SWcRCT is feasible with minor modifications. REGISTRATION: ISRCTN15516596.

Clinical indicators to identify neuropathic pain in low back-related leg pain: protocol for a modified Delphi study.

INTRODUCTION: Neuropathic low back-related leg pain (LBLP) can be a challenge to healthcare providers to diagnose and treat. Accurate diagnosis of neuropathic pain is fundamental to ensure appropriate intervention is given. However, to date there is no gold standard to diagnose neuropathic LBLP. A Delphi study will therefore be conducted to obtain an expert-derived consensus list of clinical indicators to identify a neuropathic component to LBLP. METHODS/ANALYSIS: Included participants will be considered experts within the field as measured against a predefined eligibility criterion. Through an iterative multistage process, participants will rate their agreement with a list of clinical indicators and suggest any missing clinical indicators during each round. Agreement will be measured using a 5-point Likert scale. Descriptive statistics will be used to measure agreement; median, IQR and percentage of agreement. A priori consensus criteria will be defined for each round. Data analysis at the end of round three will enable a list of clinical indicators to be derived. ETHICS AND DISSEMINATION: Ethical approval was gained from the University of Birmingham (ERN_19-1142). On completion of the study, findings will be disseminated in a peer-reviewed journal and presented at relevant conferences.

Exploring the concept of pain of Australian children with and without pain: qualitative study.

OBJECTIVE: A person's concept of pain can be defined as how they understand what pain actually is, what function it serves and what biological processes are thought to underpin it. This study aimed to explore the concept of pain in children with and without persistent pain. DESIGN: In-depth, face-to-face interviews with drawing tasks were conducted with 16 children (aged 8-12 years) in New South Wales, Australia. Thematic analysis was used to analyse and synthesise the data. SETTING: Children with persistent pain were identified from a pain clinic waiting list in Australia, and children without pain were identified through advertising flyers and email bulletins at a university and hospital. PARTICIPANTS: Eight children had persistent pain and eight children were pain free. RESULTS: Four themes emerged from the data: 'my pain-related knowledge', 'pain in the world around me', 'pain in me' and 'communicating my concept of pain'. A conceptual framework of the potential interactions between the themes resulting from the analysis is proposed. The concept of pain of Australian children aged 8-12 years varied depending on their knowledge, experiences and literacy levels. For example, when undertaking a drawing task, children with persistent pain tended to draw emotional elements to describe pain, whereas children who were pain free did not. CONCLUSIONS: Gaining an in-depth understanding of a child's previous pain-related experiences and knowledge is important to facilitate clear and meaningful pain science education. The use of age-appropriate language, in combination with appropriate assessment and education tasks such as drawing and discussing vignettes, allowed children to communicate their individual concept of pain.

The use of physiotherapy in nursing homes internationally: A systematic review.

BACKGROUND: Physiotherapy can improve functional ability, prevent falls and reduce pain for older adults in nursing homes. However, there are no legislations or guidelines that specify the parameters of physiotherapy required in nursing homes. With the increasing healthcare demands of ageing populations worldwide, it is important to understand the current use of physiotherapy services to ensure they are both evidence-based and promote equity. OBJECTIVES: (1) When and how are physiotherapy services used by older adults living in nursing homes? (2) What are the factors associated with use of physiotherapy services in nursing homes? (3) How are physiotherapy services in nursing homes documented and monitored? METHODS: Several databases and grey literature (including MEDLINE, PubMed, Pedro and EMBASE) were searched following PRISMA guidelines in March 2018. Searches were limited to English language publications from 1997. Assessment for inclusion, data extraction and quality assessment were completed by two investigators independently using standardised forms. Studies were included if they considered any type of physiotherapy service that involved a qualified physiotherapist (such as exercise, massage and staff education) with older adults (aged 60 years and older) that were primarily permanent residents of a nursing home. Data extracted included proportion of clients that used physiotherapy services, type, frequency and duration of physiotherapy services, and factors associated with physiotherapy service use. RESULTS: Eleven studies were included. Between 10% and 67% of nursing home clients used physiotherapy services. Factors associated with greater use of physiotherapy services included larger size facilities, and if clients had a physical impairment and mild or no cognitive impairment. Types of physiotherapy services reported were pain management and pressure ulcer management. CONCLUSIONS: Physiotherapy service use in nursing homes varied widely. The development of physiotherapy benchmarks and quality standards are needed to support older adults in nursing homes. PROSPERO registration number: CRD42018082460.