D. Evans

The Effectiveness of a Posted Information Package on the Beliefs and Behavior of Musculoskeletal Practitioners : The UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) Randomized Trial

Study Design. Randomized controlled trial. Objective. To investigate the effect of a printed information package on the low back pain (LBP)-related beliefs and reported behavior of musculoskeletal practitioners (chiropractors, osteopaths, and musculoskeletal physiotherapists) across the United Kingdom. Summary of Background Data. A substantial proportion of musculoskeletal practitioners in United Kingdom does not follow current LBP guideline recommendations. Methods. In total, 1758 practitioners were randomly allocated to either of the 2 study arms. One arm was posted a printed information package containing guideline recommendations for the management of LBP (n = 876) and the other received no intervention (n = 882). The primary outcome measure consisted of 3 “quality indicators” (activity, work, and bed-rest) relating to a vignette of a patient with LBP, in which responses were dichotomized into either “guideline-inconsistent” or “guideline-consistent.” The secondary outcome was the practitioners LBP-related beliefs, measured using the Health Care Providers Pain and Impairment Relationship Scale. Outcomes were measured at baseline and at 6 months. Results. Follow-up at 6 months was 89%. The changes in reported behavior on the quality indicators were as follows: activity, odds ratio (OR) 1.29 (95% confidence interval, 1.03–1.61) and number needed to be treated (NNT), 19 (15–28); work, OR 1.35 (1.07–1.70) and NNT 19 (14–29); and bed-rest, OR 1.31 (0.97–1.76) and NNT 47 (33–103). The composite NNT for a change from guideline-inconsistent to guideline-consistent behavior on at least 1 of the 3 quality indicators was 10 (9–14). LBP-related beliefs were significantly improved in those who were sent the information package (P = 0.002), but only to a small degree (mean difference, 0.884 scale points; 95% confidence interval, 0.319–1.448). Conclusion. Printed educational material can shift LBP-related beliefs and reported behaviors of musculoskeletal practitioners, toward practice that is more in line with guideline recommendations.

Would increasing centre volumes improve patient outcomes in peritoneal dialysis? A registry-based cohort and Monte Carlo simulation study

Objective To estimate the association between centre volume and patient outcomes in peritoneal dialysis, explore robustness to residual confounding and predict the impact of policies to increase centre volumes. Design Registry-based cohort study with probabilistic sensitivity analysis and Monte Carlo simulation of (hypothetical) intervention effects. Setting 112 secondary-care centres in France. Participants 9602 adult patients initiating peritoneal dialysis. Main outcome measures Technique failure (ie, permanent transfer to haemodialysis), renal transplantation and death while on peritoneal dialysis within 5u2005years of initiating treatment. Associations with underlying risk measured by cause-specific HRs (cs-HRs) and with cumulative incidence by subdistribution HRs (sd-HRs). Intervention effects measured by predicted mean change in cumulative incidences. Results Higher volume centres had more patients with diabetes and were more frequently academic centres or associative groupings of private physicians. Patients in higher volume centres had a reduced risk of technique failure (>60 patients vs 0–10 patients: adjusted cs-HR 0.46; 95% CI 0.43 to 0.69), with no changed risk of death or transplantation. Sensitivity analyses mitigated the cs-HRs without changing the findings. In higher volume centres, the cumulative incidence was reduced for technique failure (>60 patients vs 0–10 patients: adjusted sd-HR 0.49; 95% CI 0.29 to 0.85) but was increased for transplantation and death (>60 patients vs 0–10 patients: transplantation—adjusted sd-HR 1.53; 95% CI 1.04 to 2.24; death—adjusted sd-HR 1.28; 95% CI 1.00 to 1.63). The predicted reduction in cumulative incidence of technique failure was largest under a scenario of shifting all patients to the two highest volume centre groups (0.091 reduction) but lower for three more realistic interventions (around 0.06 reduction). Conclusions Patients initiating peritoneal dialysis in high-volume centres had a considerably reduced risk of technique failure but simulations of interventions to increase exposure to high-volume centres yielded only modest improvements.

Inclusion and exclusion criteria used in non-specific low back pain trials : a review of randomised controlled trials published between 2006 and 2012

BackgroundLow back pain is a common health complaint resulting in substantial economic burden. Each year, upwards of 20 randomised controlled trials (RCTs) evaluating interventions for non-specific low back pain are published. Use of the term non-specific low back pain has been criticised on the grounds of encouraging heterogeneity and hampering interpretation of findings due to possible heterogeneous causes, challenging meta-analyses. We explored selection criteria used in trials of treatments for nsLBP.MethodsA systematic review of English-language reports of RCTs in nsLBP population samples, published between 2006 and 2012, identified from MEDLINE, EMBASE, and the Cochrane Library databases, using a mixed-methods approach to analysis. Study inclusion and exclusion criteria were extracted, thematically categorised, and then descriptive statistics were used to summarise the prevalence by emerging category.ResultsWe included 168 studies. Two inclusion themes (anatomical area, and symptoms and signs) were identified. Anatomical area was most reported as between costal margins and gluteal folds (nxa0=u20098, 5%), while low back pain (nxa0=u2009150, 89%) with or without referred leg pain (nxa0=u200927, 16%) was the most reported symptom. Exclusion criteria comprised 21 themes. Previous or scheduled surgery (nxa0=u200984, 50%), pregnancy (nxa0=u200981, 48%), malignancy (nxa0=u200978, 46%), trauma (nxa0=u200963, 37%) and psychological conditions (nxa0=u200958, 34%) were the most common. Sub-themes of exclusion criteria mostly related to neurological signs and symptoms: nerve root compromise (nxa0=u200944, 26%), neurological signs (nxa0=u200934, 20%) or disc herniation (nxa0=u200930, 18%). Specific conditions that were most often exclusion criteria were spondylolisthesis (nxa0=u200935, 21%), spinal stenosis (nxa0=u200931, 18%) or osteoporosis (nxa0=u200927, 16%).ConclusionRCTs of interventions for non-specific low back pain have incorporated diverse inclusion and exclusion criteria. Guidance on standardisation of inclusion and exclusion criteria for nsLBP trials will increase clinical homogeneity, facilitating greater interpretation of between-trial comparisons and meta-analyses. We propose a template for reporting inclusion and exclusion criteria.

Development of a screening tool to predict the risk of chronic pain and disability following musculoskeletal trauma: protocol for a prospective observational study in the United Kingdom

Introduction Pain is an expected and appropriate experience following traumatic musculoskeletal injury. By contrast, chronic pain and disability are unhelpful yet common sequelae of trauma-related injuries. Presently, the mechanisms that underlie the transition from acute to chronic disabling post-traumatic pain are not fully understood. Such knowledge would facilitate the development and implementation of precision rehabilitation approaches that match interventions to projected risk of recovery, with the aim of preventing poor long-term outcomes. The aim of this study is to identify a set of predictive factors to identify patients at risk of developing ongoing post-traumatic pain and disability following acute musculoskeletal trauma. To achieve this, we will use a unique and comprehensive combination of patient-reported outcome measures, psychophysical testing and biomarkers. Methods and analysis A prospective observational study will recruit two temporally staggered cohorts (n=250u2009each cohort; at least 10 cases per candidate predictor) of consecutive patients with acute musculoskeletal trauma aged ≥16 years, who are emergency admissions into a Major Trauma Centre in the United Kingdom, with an episode inception defined as the traumatic event. The first cohort will identify candidate predictors to develop a screening tool to predict development of chronic and disabling pain, and the second will allow evaluation of the predictive performance of the tool (validation). The outcome being predicted is an individual’s absolute risk of poor outcome measured at a 6-month follow-up using the Chronic Pain Grade Scale (poor outcome ≥grade II). Candidate predictors encompass the four primary mechanisms of pain: nociceptive (eg, injury location), neuropathic (eg, painDETECT), inflammatory (biomarkers) and nociplastic (eg, quantitative sensory testing). Concurrently, patient-reported outcome measures will assess general health and psychosocial factors (eg, pain self-efficacy). Risk of poor outcome will be calculated using multiple variable regression analysis. Ethics and dissemination Approved by the NHS Research Ethics Committee (17/WA/0421).