Patient perspectives on data sharing regarding implementing and using artificial intelligence in general practice - a qualitative study.

BACKGROUND: Due to more elderly and patients with complex illnesses, there is an increasing pressure on the healthcare system. General practice especially feels this pressure as being the first point of contact for the patients. Developments in digitalization have undergone fast progress and data-driven artificial intelligence (AI) has shown great potential for use in general practice. To develop AI as a support tool for general practitioners (GPs), access to patients' health data is needed, but patients have concerns regarding data sharing. Furthermore, studies show that trust is important regarding the patient-GP relationship, data sharing, and AI. The aim of this paper is to uncover patient perspectives on trust regarding the patient-GP relationship, data sharing and AI in general practice. METHOD: This study investigated 10 patients' perspectives through qualitative interviews and written vignettes were chosen to elicit the patients (interviewees) perspectives on topics that they were not familiar with prior to the interviews. The study specifically investigated perspectives on 1) The patient-GP relationship, 2) data sharing regarding developing AI for general practice, and 3) implementation and use of AI in general practice using thematic analysis. The study took place in the North Denmark Region and the interviewees included had to be registered in general practice and be above 18 years in age. We included four men between 25 to 74 years in age and six women between 27 to 46 years in age. RESULTS: The interviewees expressed a high level of trust towards their GP and were willing to share their health data with their GP. The interviewees believed that AI could be a great help to GPs if used as a support tool in general practice. However, it was important for the interviewees that the GP would still be the primary decision maker. CONCLUSION: Patients may be willing to share health data to help implement and use AI in general practice. If AI is implemented in a way that preserves the patient-GP relationship and used as a support tool for the GP, our results indicate that patients may be positive towards the use of AI in general practice.

General Practitioners' Perspectives on Appropriate Use of Ultrasonography in Primary Care in Denmark: A Multistage Mixed Methods Study.

PURPOSE: Researchers aimed to describe general practitioners' understanding of appropriate ultrasound use, to record actual scanning practices of early adopters in general practice, and to identify differences between attitudes and actual practice via a mixed methods analysis. METHODS: This study was part of a larger multistage mixed methods research framework exploring the use of ultrasound in general practice in Denmark. We used an exploratory sequential approach in the data collection with initial qualitative findings from an interview study applied to building a quantitative questionnaire utilized in a cohort study. In addition, we merged the qualitative and quantitative data using joint display analysis to compare and contrast the results from the 2 stages of the study. RESULTS: In the interviews, general practitioners described appropriate ultrasound use as point-of-care examinations with a clear purpose and limited to predefined specific conditions within delimited anatomic areas. They stated that general practitioners should receive formalized ultrasound training and be skilled in the examinations they perform. In the cohort study, general practitioners performed ultrasound examinations of anatomic areas with or without a defined clinical suspicion. Some performed ultrasound examinations for which they had no previous training or skills. CONCLUSIONS: We found a difference between the ideas about the appropriate uses for ultrasound in general practice and the actual use by early adopters in clinical practice. Our findings suggest a need for evidence-based guidelines to support general practitioners in choosing which examinations to perform and strategies for developing and maintaining scanning competency.

A cost-minimisation analysis of performing point-of-care ultrasonography on patients with vaginal bleeding in early pregnancy in general practice: a decision analytical model.

BACKGROUND: Spotting and light vaginal bleeding are common and usually harmless symptoms in early pregnancy. Still, vaginal bleeding may be the first sign of an abortion and often causes distress to pregnant women and leads to an expectation of an ultrasonography examination of the uterus. As point-of-care ultrasonography (POCUS) is increasingly being integrated into general practice, these patients may be clinically evaluated and managed by general practitioners (GPs). This can potentially reduce referrals of patients from the primary to the secondary healthcare sector resulting in societal cost-savings. The primary purpose of this study was to investigate whether the accessibility of POCUS in general practice for patients with vaginal bleeding in early pregnancy is cost-saving compared to usual practice where GPs do not have access to POCUS. A secondary purpose of this study was to estimate a remuneration for GPs performing POCUS on these patients in general practice. METHODS: A cost-minimisation analysis was based on a decision tree model reflecting the two alternatives: general practice with and without GPs having access to POCUS. The robustness of the model results was investigated using probabilistic sensitivity analysis and the following deterministic sensitivity analyses: one-way analyses for the model input parameters and a scenario analysis with a change from a societal to a healthcare sector perspective. An expected remuneration reflecting the add-on cost of Danish GPs performing POCUS was estimated based on the related costs: cost of an ultrasonography scanner, GP's time consumption, ultrasonography training, and utensils per scanning. RESULTS: The difference in average cost between the two alternatives from a societal perspective was estimated to be €110, in favour of general practice with GPs using POCUS. The deterministic sensitivity analyses demonstrated robustness of the results to plausible changes in the input parameters. The expected remuneration for performing POCUS in this specific setting was estimated to be €32 per examination. CONCLUSION: Having GPs perform POCUS on patients with vaginal bleeding in early pregnancy is cost-saving compared to usual practice. The results should be taken with caution as this study was based on early modelling with uncertainties associated with the input parameters in the model.

Learning strategies of general practitioners striving to achieve point-of-care ultrasound competence: a qualitative study.

BACKGROUND: Point-of-care ultrasonography (POCUS) is increasingly used in general practice despite the lack of official educational programmes or guidelines for general practitioners (GPs). AIM: To explore how GPs have learnt to use POCUS and which barriers they have encountered in their learning process. DESIGN AND SETTING: Qualitative study conducted in office-based general practice in Denmark. METHODS: Semi-structured interviews were conducted with 13 GPs who had implemented POCUS without supporting guidelines or regulations. Analysis was carried out using systematic text condensation. The interview data for this study were collected along with data used in a previous study. RESULTS: The participating GPs described having composed their own ultrasound education following a continuous learning process. Basic POCUS competences were achieved through formalized training sessions at hospital departments or courses. The GPs further developed and expanded their scanning skills through additional courses and continuous self-study practice on patients often while consulting internet sources, textbooks or colleagues. Lack of available ultrasound courses, supervision, and clinical guidelines together with time constraints and financial aspects were mentioned as barriers to their ultrasound training. CONCLUSION: This study showed how GPs had composed their own ultrasound education individually and differently, guided by their own experiences and beliefs about good clinical practice. Formalized ultrasound training was considered a prerequisite for achieving basic ultrasound competences while continuous practice was considered paramount to develop and maintain scanning skills. There were several obstacles to overcome in the learning process including lack of supervision, guidance, and opportunity for practicing skills.Key pointsLittle is known about the educational needs of general practitioners striving to achieve ultrasound competences.General practitioners described using formalized training to achieve basic scanning competences and continuous self-study and practice to further develop their skills.Lack of time, supervision, clinical guidelines and ultrasound courses were considered barriers in the learning process together with financial aspects.

Education of general practitioners in the use of point-of-care ultrasonography: a systematic review.

OBJECTIVE: To systematically review and synthesize the published literature regarding the education of general practitioners (GPs) and GPs in training (GPTs) in the use of ultrasonography. DESIGN: This systematic review was prospectively registered in PROSPERO, conducted according to the Cochrane recommendations. We combined studies identified in a previous systematic review with studies from an updated literature search using the same search string. We searched the following databases: MEDLINE via Pubmed, EMBASE via OVID, Cinahl via Ebsco, Web of Science and Cochrane Register of Controlled Trials using the words 'ultrasonography' and 'general practice'. Two reviewers independently screened articles, extracted data and assessed the quality of included papers according to the Down and Black quality assessment tool. Disagreements were resolved by involving a third reviewer. RESULTS: Thirty-three papers were included. Ultrasound training was described to include both theoretical and practical training sessions. Theoretical training was achieved through introductory e-learning and/or didactic lectures. Practical training included focussed hands-on training sessions, while some papers described additional longitudinal practical training through proctored scans during clinical work or through self-study practice with continuous feedback on recorded scans. CONCLUSION: There was a large variation in ultrasound training programs for GPs and GPTs, with an overall emphasis on focussed practical training. Few studies included a longitudinal learning process in the training program. However, diagnostic accuracy seemed to improve with hours of practical training, and studies including continuous feedback on scans conducted during clinical patient encounters showed superior results.

Point-of-care ultrasonography is increasingly used by general practitioners (GPs) working in primary care as a diagnostic tool providing earlier and more precise diagnoses. However, ultrasonography is a user-dependent technology and obtaining competence requires both training and practice. Today, there is no consensus about which ultrasound training GPs should have before they start scanning patients in their clinics.

Introducing point-of-care ultrasound in Danish general practice-elucidating the use through a medical audit.

BACKGROUND: Point-of-care ultrasonography (PoCUS) is increasingly used across the medical field. PoCUS is also being implemented in general practice despite a lack of clinical guidelines and training programs for general practitioners (GPs). OBJECTIVES: This study aimed to elucidate the employment of PoCUS by Danish GPs following a short training program. METHODS: Thirty GPs were enrolled in a short ultrasound training program and taught how to perform 22 selected scanning modalities. In the following 3 months, the GPs registered all performed PoCUS examinations according to the Audit Project Odense method. After 5 months, the GPs were invited to participate in an evaluation seminar, where questionnaires were distributed. RESULTS: During the registration period, 1598 patients were examined with PoCUS. A total of 1948 scanning modalities were registered, including 207 examinations outside the taught curriculum. The majority of the ultrasound examinations were performed within 10 minutes (89%), most were considered to be conclusive (87%) and/or to increase diagnostic certainty (67%), whereas one in four examinations entailed a change in patient management. Most GPs attending the evaluation seminar continued to use PoCUS and found the scanning modalities included in the course curriculum relevant in their daily work. CONCLUSION: The GPs found several indications for performing PoCUS following the attendance of a 2-day basic training program. The majority of examinations were registered to be conclusive and/or increase diagnostic certainty. However, few GPs used PoCUS on a daily basis and not all examinations were registered to have an impact on patient care.

Supervised Training Compared With No Training or Self-training in Patients With Subacromial Pain Syndrome: A Systematic Review and Meta-analysis.

OBJECTIVE: To study the effects of supervised training in adults with subacromial pain syndrome. DATA SOURCES: Embase, MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database were searched from inception to March 2020. STUDY SELECTION: Independent reviewers selected randomized controlled trials comparing supervised training with (1) no training or (2) self-training in adults with subacromial pain syndrome lasting for at least 1 month. Critical outcomes were shoulder pain, function, and patient-perceived effect. Important outcomes included other potential benefits and adverse events at 3-month follow-up. DATA EXTRACTION: Two independent reviewers extracted data for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool 1, and certainty of evidence was evaluated using the Grades of Recommendation Assessment, Development, and Evaluation (GRADE). DATA SYNTHESIS: Ten studies (n=597, 43% female) were included. Supervised training resulted in larger improvements than no training on pain (at rest: n=286; mean difference [MD], 1.68; 95% confidence interval [CI], 0.31-3.06 on 0-10 scale; during movement: n=353; MD, 1.84; 95% CI,0.91-2.76), function (n=396; standardized MD, 0.30; 95% CI, 0.07-0.52), and patient-perceived effect (n=118; risk ratio, 1.43; 95% CI, 0.87-2.34). Supervised training had potential benefits regarding quality of life, return to work, dropout, and training adherence, albeit more patients reported mild, transient pain after training. Supervised training and self-training showed equal improvements on pain (n=44) and function (n=76), with no data describing patient-perceived effect. Certainty of evidence was low for critical outcomes and low-moderate for other outcomes. CONCLUSIONS: Supervised training might be superior to no training and equally effective as self-training on critical and important outcomes. Based on low-moderate certainty of evidence, these findings support a weak recommendation for supervised training in adults with subacromial pain syndrome.

Patients' experiences of the use of point-of-care ultrasound in general practice - a cross-sectional study.

BACKGROUND: The use of point-of-care ultrasonography (POCUS) performed by general practitioners (GPs) in primary care settings is increasing. Previous studies have focused on GP-reported outcomes and little is known about patients' perspectives on the use of POCUS technology within the general practice consultation. The purpose of this study was to examine patients' experiences with POCUS in general practice within the areas where GPs have indicated that POCUS affected aspects of the consultation. METHODS: A questionnaire was developed using a mixed methods sequential design. Analytical themes from interviews with GPs were converted into items in a questionnaire by the research team. The questionnaire was then further developed in several rounds of pilot tests involving both patients and GPs. The final questionnaire was used in a cohort study conducted in 18 Danish office-based general practice clinics from January 2018 to August 2018. All patients examined with POCUS were asked to complete the questionnaire on tablets immediately after their consultation. RESULTS: Out of 691 patients examined, 564 (81.6%) questionnaires were available for analysis. The patients reported that they were well informed about the purpose (98%) and the results (97%) of the POCUS examination; however, 29% reported that they were not informed about the difference between POCUS and an imaging-specialist's ultrasound examination. Almost all patients (99%) reported that POCUS was integrated naturally into the consultation, and 45% reported that POCUS improved the doctor-patient relationship. The majority of patients felt that they had been more thoroughly examined (92%) and taken more seriously (58%) when POCUS was part of the consultation. They felt POCUS gave them a better understanding of their health problem (82%), made them feel more secure (86%) and increased their trust in the physician's assessment (65%). Moreover, the patients reported that POCUS use improved the level of service (95%) they experienced and the quality of care (94%) in general practice. CONCLUSION: We found that an examination including POCUS in general practice was a positive experience overall for the majority of patients. Future research should further explore reasons for patient confidence in POCUS and whether or not the reassuring value of POCUS is valid. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03416608.

Facilitators and barriers in diagnosing rheumatoid arthritis as described by general practitioners: a Danish study based on focus group interviews.

OBJECTIVE: To explore the perspectives of general practitioners (GPs) on facilitators and barriers in diagnosing rheumatoid arthritis (RA). DESIGN: Qualitative study based on focus group interviews, and using latent thematic analysis. SETTING: General practices from Central Region Denmark. SUBJECTS: Eleven GPs participated in three different focus groups. Forty percent were female, the mean age was 53 years (range 37-64), and the mean since medical licensing was 16 years (range 5-23). Sixty percent of the GPs worked in an area served by a university hospital, and 40% were served by a regional hospital. MAIN OUTCOME MEASURE: Themes describing experiences and reflections about facilitators and barriers in diagnosing Rheumatoid Arthritis. RESULTS: Four themes emerged: (A) If the patient is not a textbook example, (B) The importance of maintaining the gatekeeper function, (C) Difficulties in referral of patients to the rheumatologist, and (D) Laboratory tests-can they be trusted? Barriers were identified in all themes, but facilitators only in A, C, and D. The overarching theme was Like finding a needle in a haystack. CONCLUSION: The GPs found several barriers for diagnosing RA (symptom awareness, GP's gatekeeper function, suboptimal collaboration with rheumatologists and limitations in laboratory tests). They identified education, more specific tests and better access to rheumatologists as possible facilitators for diagnosing RA. To facilitate earlier referral of suspected RA in general practice and strengthen mutual information and collaboration, future research should focus on these facilitators and barriers.KeypointsEarly diagnosis is essential for the prognosis of RA, and the diagnostic process begins in general practice.Suggested facilitators: training courses in interpretation of laboratory tests and the clinical manifestation of RA, and videos on joint examinations.Suggested barriers: compliance with the gatekeeper function, suboptimal collaboration with rheumatologists, limitations of laboratory tests, and diversity of clinical manifestations.

Point-of-care ultrasound for general practitioners: a systematic needs assessment.

Objective: The aim of the study was to achieve consensus among a group of ultrasound proficient general practitioners (GPs) from Denmark, Norway, Sweden and Finland on which ultrasound scanning modalities and ultrasound-guided procedures are essential to GPs in their daily work for the purpose of including them in a basic ultrasound curriculum.Design: The Delphi methodology was used to obtain consensus.Subjects: Sixty Scandinavian GPs with more than two years of point-of-care ultrasound (POCUS) experience were invited to join the Delphi expert panel.Main outcome measures: In the first Delphi round each member of the panel was asked to produce a list of scanning modalities and procedures which they found relevant to include in a basic ultrasound curriculum. In Delphi round two, these suggestions were presented to the entire panel who assessed whether they found them essential in their daily work. Items not reaching consensus in round two, were presented to the panel in a third and final round. Items reaching more than 67% agreement were included.Results: Forty-five GPs were included in the study and 41 GPs completed all rounds. Agreement was obtained on 30 scanning modalities and procedures primarily within the musculoskeletal (8), abdominal (5), obstetric (5) and soft tissue (3) diagnostic areas. Four ultrasound-guided procedures were also agreed upon.Conclusion: A prioritized list of 30 scanning modalities and procedures was agreed upon by a group of ultrasound proficient GPs. This list could serve as a guideline when planning future POCUS educational activities for GPs.Key pointsPoint-of-care ultrasound (POCUS) is increasingly being used by general practitioners (GPs), but little is known about which ultrasound applications are most used.We performed a systematic needs assessment among a group of ultrasound proficient GPs using the Delphi methodology for the purpose of establishing a basic POCUS curriculum.The process resulted in a prioritized list of 30 scanning modalities and ultrasound guided procedures.Our study provides the basis for an evidence-based basic POCUS curriculum for GPs.

Point-of-Care Ultrasound in General Practice: A Systematic Review.

PURPOSE: Ultrasound examinations are currently being implemented in general practice. This study aimed to systematically review the literature on the training in and use of point-of-care ultrasound (POCUS) by general practitioners. METHODS: We followed the Cochrane guidelines for conduct and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. We searched the databases MEDLINE (via PubMed), EMBASE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials using the key words ultrasonography and general practice in combination and using thesaurus terms. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS: We included in our review a total of 51 full-text articles. POCUS was applied for a variety of purposes, with the majority of scans focused on abdominal and obstetric indications. The length of training programs varied from 2 to 320 hours. Competence in some types of focused ultrasound scans could be attained with only few hours of training. Focused POCUS scans were reported to have a higher diagnostic accuracy and be associated with less harm than more comprehensive scans or screening scans. The included studies were of a low quality, however, mainly because of issues with design and reporting. CONCLUSIONS: POCUS has the potential to be an important tool for the general practitioner and may possibly reduce health care costs. Future research should aim to assess the quality of ultrasound scans in broader groups of general practitioners, further explore how these clinicians should be trained, and evaluate the clinical course of patients who undergo scanning by general practitioners.

Danish general practitioners have found their own way of using point-of-care ultrasonography in primary care: a qualitative study.

BACKGROUND: General practitioners increasingly use point-of-care ultrasonography despite a lack of evidence-based guidelines for their appropriate use in primary care. Little is known about the integration of ultrasonography in general practice consultations and the impact of its use on patient care. The purpose of this study was to explore general practitioners' experiences of using ultrasonography in the primary care setting. METHODS: Adopting an explorative phenomenological approach, we performed semi-structured interviews with general practitioners who used ultrasonography in their daily work. Thirteen general practitioners were recruited stepwise, aiming for maximum variation in background characteristics. Interviews were conducted at the general practitioner's own clinic. Transcription and systematic text condensation analysis began immediately after conducting each interview. RESULTS: The general practitioners described using ultrasonography for both selected focused examinations and for explorative examinations. The two types of examinations were described differently for each of the following emerging themes: motivation for using ultrasonography, ultrasonography as part of the consultation, selection of an ultrasound catalogue, and consequences of the general practitioner's ultrasound examination. The general practitioners had chosen and integrated their own individual ultrasound catalogue of focused examinations as a natural part of their consultations. The focused examinations were used to answer simple clinical questions and they had a significant impact on the patients' diagnoses, clinical pathways and treatments. The general practitioners considered their own catalogue of focused examinations as their comfort zone. However, they also performed explorative ultrasound examinations outside their catalogue. These scans were performed to train, gain or maintain ultrasound competences or as explorative examinations driven by curiosity. The explorative ultrasound examinations rarely had an impact on patient care. CONCLUSIONS: This study describes how general practitioners found their own way of using ultrasonography in general practice and selected a personal catalogue of ultrasound examinations that was applicable, relevant and meaningful for their daily clinical routines. This study may serve to inform implementation strategies in general practice by offering insights into central aspects that drive general practitioners' behaviours.

Prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice: a registry-based study.

BACKGROUND: Tendinopathies of the lower extremity (e.g. Achilles, patellar, and plantar heel pain) are common in both general and sporting populations. However, the prevalence and incidence in Danish general practice is unknown. The aim was to determine the prevalence and incidence rate of lower-extremity tendinopathies in a Danish general practice. METHODS: In this registry-based study, we extracted data from the electronic patient files of all patients in a single Danish general practice. The practice included 8836 patients. We searched ICPC-2 codes to identify patients with either of the following lower-extremity tendinopathies: plantar heel pain; Achilles tendinopathy; patellar tendinopathy; greater trochanteric pain syndrome or adductor tendinopathy. We defined an incident and prevalent case as a patient with a consultation because of tendinopathy in 2016 only. A prevalent, but not incident case was a patient with consultations in both 2015 and 2016. Incidence and prevalence were expressed as the number of patients with a tendinopathy per 1000 registered patients. RESULTS: The prevalence and incidence rate were 16.6 and 7.9 per 1000 registered patients, respectively. Plantar heel pain was the most prevalent tendinopathy and accounted for 39% of lower-extremity tendinopathies. Patients with tendinopathies were significantly older than all registered patients (46.0 years (95%CI: 43.3;48.7) versus 38.8 years (95%CI: 38.4;39.3), respectively). CONCLUSIONS: Lower-extremity tendinopathies, especially plantar heel pain, had a high prevalence and incidence rate in a Danish general practice. In a typical general practice with 5000 patients, general practitioners should expect to see more than 80 patients with a lower-extremity tendinopathy every year.

Requirements for implementing online information material for patients with low back pain in general practice: an interview study.

OBJECTIVE: To identify general practitioners' (GPs) barriers and facilitators regarding the use of health information technology (HIT) in the treatment of patients with low back pain (LBP). DESIGN: A qualitative study employing a participatory design approach, with an inductive analytical thematic approach utilising semi-structured interviews. Empirical data was analysed using the qualitative data analysis software (QDAS) Nvivo. SETTING: General practices in Denmark. SUBJECTS: Eight interviews were conducted with an average duration of 60 min. The interviewees were GPs from different geographical settings and different organisational structures, varying in age and professional interests. MAIN OUTCOME MEASURES: Barriers and facilitators for future use of the HIT application for patients with LBP. RESULTS: Through the inclusion of healthcare professionals in the design process, this study found that in order for GPs to recommend a HIT application it is essential to target the application towards their patients. Furthermore, GPs required that the HIT application should support patient self-management. Additionally, the content of the HIT application should support the initiated treatment and it should be easy for GPs to recommend the HIT application. Finally, healthcare professionals need to be involved in the design process. CONCLUSION: When designing health IT applications for patients with LBP in general practice it is important to include both patients and GPs in the design process. GPs would be more willing to recommend a HIT application that: applies content in line with frequently used recommendations; targets patients; supports patients' self-management; and supports the patients' needs. KEY POINTS Online information is currently applied in general practice to some patients with low back pain Online information cannot replace the GP, but can rather be a bonding tool between the patient and the GP It is important to address both GP and patient barriers to applying new technology and to consider the literacy level Participatory methods could play a central role in the future development of online information material.

The effect of isometric exercise on pain in individuals with plantar fasciopathy: A randomized crossover trial.

Isometric exercise is commonly recommended for immediate pain relief in individuals suffering from lower limb tendinopathies, despite the limited evidence supporting its analgesic effect. Due to the similarities between plantar fasciopathy and tendinopathies, the aim of this trial was to investigate the acute effect of isometric exercise on pain, compared to isotonic exercise, or walking, in individuals with plantar fasciopathy. We recruited 20 individuals with plantar fasciopathy for this prospectively-registered, participant-blinded, randomized, superiority crossover trial (ClinicalTrials.gov: NCT03264729). Participants attended three exercise sessions (isometric, isotonic, or walking) in a randomized order, within a 2-week period. Both isometric and isotonic exercises were performed standing with the forefoot on a step bench, while walking was performed barefoot. The primary outcome was pain (measured on a 0-100-mm VAS) during a pain-aggravating activity. Secondary outcomes included pressure pain threshold (PPT) under the heel, and plantar fascia thickness (PFT). All outcomes were measured before and after each exercise session. There were no significant differences between the three exercises on pain (P = 0.753), PPTs (P = 0.837), or PFT (P = 0.718). Further, there was no change in pain from before to after any of the exercises (isometric exercise 2.7 mm [95% CI: -12.2; 6.8], isotonic exercise -3.4 mm [95% CI: -5.0; 11.8], or walking 1.6 mm [95% CI: -16.1; 12.9]). Contrary to expectations, isometric exercise was no better than isotonic exercise or walking at reducing pain in individuals with plantar fasciopathy. None of the exercises induced any systematic analgesic effect.

National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy.

PURPOSE: To summarise recommendations about 20 non-surgical interventions for recent onset (<12 weeks) non-specific low back pain (LBP) and lumbar radiculopathy (LR) based on two guidelines from the Danish Health Authority. METHODS: Two multidisciplinary working groups formulated recommendations based on the GRADE approach. RESULTS: Sixteen recommendations were based on evidence, and four on consensus. Management of LBP and LR should include information about prognosis, warning signs, and advise to remain active. If treatment is needed, the guidelines suggest using patient education, different types of supervised exercise, and manual therapy. The guidelines recommend against acupuncture, routine use of imaging, targeted treatment, extraforaminal glucocorticoid injection, paracetamol, NSAIDs, and opioids. CONCLUSION: Recommendations are based on low to moderate quality evidence or on consensus, but are well aligned with recommendations from international guidelines. The guideline working groups recommend that research efforts in relation to all aspects of management of LBP and LR be intensified.

How can we implement exercise therapy for patellofemoral pain if we don't know what was prescribed? A systematic review.

OBJECTIVE: To evaluate the completeness of exercise prescription in randomised controlled trials (RCTs) for patellofemoral pain (PFP), identify which elements are most frequently missing and supplement recommendations based on additional data from authors. DESIGN: Systematic review. DATA SOURCES: All studies included in the most recent Cochrane review were evaluated. Additionally, the Cochrane search was updated in June 2016 in Cochrane, MEDLINE, EMBASE, PEDro, CINAHL and AMED databases. Two raters independently assessed completeness of reporting using the Toigo and Boutellier mechanobiological exercise descriptors, and Template for Intervention Description and Replication (TIDieR) checklist. Authors were also contacted to provide additional information. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: RCTs of exercise interventions for PFP. RESULTS: We included 38 RCTs. The level of exercise prescription detail was low, with no study providing complete information. The most commonly reported exercise descriptors were the 'duration of the experimental period' (n=38/38) and 'number of exercise interventions' (n=35). From TIDieR, the most commonly reported items were the 'intervention name' (n=38) and 'rationale' (n=36).The least reported items from the exercise descriptors were 'volitional muscular failure', 'temporal distribution of contraction modes', 'time under tension' and 'recovery between exercise sessions' (all n=2/38). From TIDieR, the least reported item was 'How well (fidelity and adherence)' (n=3/38).36 authors were contacted, with 22 replies and 13 providing additional exercise prescription details . CONCLUSION: Exercise prescriptions in RCTs with proven efficacy for PFP are poorly reported, impairing their implementation in clinical practice. PROSPERO REGISTRATION NUMBER: CRD42016039138.

National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy.

PURPOSE: To summarise recommendations about 21 selected non-surgical interventions for recent onset (<12 weeks) non-specific neck pain (NP) and cervical radiculopathy (CR) based on two guidelines from the Danish Health Authority. METHODS: Two multidisciplinary working groups formulated recommendations based on the GRADE approach. RESULTS: Twelve recommendations were based on evidence and nine on consensus. Management should include information about prognosis, warning signs, and advise to remain active. For treatment, guidelines suggest different types of supervised exercise and manual therapy; combinations of exercise and manual therapy before medicine for NP; acupuncture for NP but not CR; traction for CR; and oral NSAID (oral or topical) and Tramadol after careful consideration for NP and CR. CONCLUSION: Recommendations are based on low-quality evidence or on consensus, but are well aligned with recommendations from guidelines from North America. The working groups recommend intensifying research relating to all aspects of management of NP and CR.

Predictive ability of the start back tool: an ancillary analysis of a low back pain trial from Danish general practice.

BACKGROUND: Low back pain (LBP) is a common cause of contact with the primary healthcare sector. In some patients, symptoms quickly resolve, but others develop long-lasting pain and disability. To improve the care pathway for patients with LBP, the STarT Back Tool (STarT) questionnaire has been developed. It helps initial decision-making by subgrouping patients on the basis of their prognosis and helps to target treatment according to prognosis. An assumption behind the use of STarT is the ability to predict functional improvement. This assumption has never been tested in a population that consists exclusively of patients enrolled when consulting a Danish general practitioner for LBP. The aim of this study was to investigate STarT's ability to predict a 30% improvement in the Roland Morris Disability Questionnaire (RMDQ) score. METHODS: This was an ancillary analysis using data from a Danish guideline implementation study (registered at ClinicalTrials.gov NCT01699256). An inclusion criterion was age 18 to 65 years of age. Exclusion criteria were pregnancy, fractures, and signs of underlying pathology. Patient-reported STarT score and the Roland Morris Disability Questionnaire were administered at baseline and again after 4, 8, and 52 weeks. RESULTS: Between January 2013 and July 2014, 475 patients from the original trial participated with questionnaires. From this subpopulation, 441 (92.8%) patients provided information regarding STarT. Baseline and eight-week RMDQ data were available for 304 (64.0%) patients. After 8 weeks, 61 (65.6%) in the low-risk group, 67 (54.9%) in the medium-risk group, and 33 (37.1%) in the high-risk group had achieved a 30% improvement in the RMDQ score. After 8 weeks, high-risk patients were at 61% (95% CI: 20-125%, P < 0.001) higher risk of not achieving a 30% improvement in the RMDQ score compared with patients in either the low-risk group or the medium-risk group. CONCLUSION: STarT was predictive for functional improvement in patients from general practice with LBP. TRIAL REGISTRATION: ClinicalTrials.gov NCT01699256 , Nov 29, 2016 (registered retrospectively).

The effect of focused lung ultrasonography on antibiotic prescribing in patients with acute lower respiratory tract infections in Danish general practice: study protocol for a pragmatic randomized controlled trial (PLUS-FLUS).

BACKGROUND: The use of antibiotics is a key driver of antimicrobial resistance and is considered a major threat to global health. In Denmark, approximately 75% of antibiotic prescriptions are issued in general practice, with acute lower respiratory tract infections (LRTIs) being one of the most common indications. Adults who present to general practice with symptoms of acute LRTI often suffer from self-limiting viral infections. However, some patients have bacterial community-acquired pneumonia (CAP), a potential life-threatening infection, that requires immediate antibiotic treatment. Importantly, no single symptom or specific point-of-care test can be used to discriminate the various diagnoses, and diagnostic uncertainty often leads to (over)use of antibiotics. At present, general practitioners (GPs) lack tools to better identify those patients who will benefit from antibiotic treatment. The primary aim of the PLUS-FLUS trial is to determine whether adults who present with symptoms of an acute LRTI in general practice and who have FLUS performed in addition to usual care are treated less frequently with antibiotics than those who only receive usual care. METHODS: Adults (≥ 18 years) presenting to general practice with acute cough (< 21 days) and at least one other symptom of acute LRTI, where the GP suspects a bacterial CAP, will be invited to participate in this pragmatic randomized controlled trial. All participants will receive usual care. Subsequently, participants will be randomized to either the control group (usual care) or to an additional focused lung ultrasonography performed by the GP (+ FLUS). The primary outcome is the proportion of participants with antibiotics prescribed at the index consultation (day 0). Secondary outcomes include comparisons of the clinical course for participants in groups. DISCUSSION: We will examine whether adults who present with symptoms of acute LRTI in general practice, who have FLUS performed in addition to usual care, have antibiotics prescribed less frequently than those given usual care alone. It is highly important that a possible reduction in antibiotic prescriptions does not compromise patients' recovery or clinical course, which we will assess closely. TRIAL REGISTRATION: ClinicalTrials.gov NCT06210282. Registered on January 17, 2024.