https://hdl.handle.net/2123/12034 2026-06-05T21:07:58Z https://hdl.handle.net/2123/35257 Diagnostic labels used by health professionals for patellofemoral pain: A cross-sectional online survey Zhang, Z.; Ferreira, G.E.; Pappas, E.; Maher, C.G.; Zadro, J.R. OBJECTIVES: To explore what diagnostic labels are commonly used by health professionals in managing patellofemoral pain (PFP), to investigate management preferences for PFP, and whether imaging findings, patient characteristics, and clinicians' expertise influence the diagnostic labels used by health professionals for PFP. METHOD: We conducted an online cross-sectional survey of health professionals with experience in managing knee pain to explore what diagnostic labels health professionals use for PFP. Demographic and outcome data were summarised using descriptive statistics. Logistic regression analyses were performed to explore whether years of experience and clinicians' expertise influence the use of diagnostic labels. RESULTS: 156 participants provided data for our primary outcome (use of diagnostic labels) and 139 completed the survey. The most used diagnostic labels for PFP were 'patellofemoral pain' (83 %), 'anterior knee pain and/or syndrome' (54 %), and 'patellofemoral pain syndrome' (44 %). The most common management strategies for PFP included exercise therapy (98 %), patient education (85 %), manual therapy (63 %), and patellar taping (58 %). Around one-third of health professionals would modify their diagnosis of PFP if imaging found a meniscal tear (37 %) or inflamed bursa/fat pad (38 %). Health professionals with self-reported excellent/good diagnostic skills or who had more years of experience were less likely to change their label based on imaging findings. CONCLUSION: Health professionals' use of diagnostic labels and management strategies for PFP mostly align with current recommendations. More research is needed to investigate the relationship between diagnostic labels and patients' management preferences, and the reasons for health professionals' choice of diagnostic labels for PFP. 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35255 Effects of diagnostic labels on management intentions for patellofemoral pain: An online randomised experimental study Zhang, Z.; Ferreira, G.; Pappas, E.; Hall, S.; Malliaras, P.; Maher, C.; Zadro, J.R. OBJECTIVES: To investigate whether different labels for patellofemoral pain influence peoples' perceived need for imaging (primary outcome), surgery, an injection, a second opinion, and relative rest and activity modification, perceived seriousness of the conditions, concern about exercise and physical activity engagement, and recovery expectations; and whether being engaged in recreational sport influenced the effect of labels on outcomes. DESIGN: Online randomised experiment. METHODS: 1080 adults with self-reported non-traumatic anterior knee pain read a vignette describing a patient with patellofemoral pain and were randomised to one of four terms describing patellofemoral pain: patellofemoral pain, anterior knee pain, runner's knee, and chondromalacia patella. Outcomes included perceived need for imaging (primary), surgery, an injection, a second opinion, and relative rest and activity modification, perceived seriousness of the conditions, concern about exercise and physical activity engagement, and recovery expectations. Participants were categorised as being engaged in recreational sports (Tegner Activity Scale ?6) or not (Tegner Activity Scale <6) for sub-group analyses. Linear regression models were used for analyses of outcomes and interaction analyses. RESULTS: Labelling did not influence any outcomes for the total sample. Labelling as anterior knee pain decreased perceived need for relative rest and activity modification compared to labelling as runner's knee and chondromalacia patella among those not engaged in recreational sports, but had no effect for those engaged in recreational sports. No other analyses were statistically significant. CONCLUSIONS: The labels patellofemoral pain, anterior knee pain, runner's knee, and chondromalacia patella have similar effects on patient management preferences for patellofemoral pain. 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35256 Perceptions of best practice, pain science and structure-focused education for rotator cuff-related shoulder pain: a content analysis of qualitative data from a randomised experiment Zhang, Z.; Ferreira, G.E.; Muller, R.; Sousa, F.; Malliaras, P.; West, C.A.; O'Keeffe, M.; Maher, C.; Zadro, J. OBJECTIVES: To explore how people perceive different forms of education for rotator cuff-related shoulder pain in terms of words or feelings evoked by the education and treatments they feel are needed. SETTING: We performed a content analysis of qualitative data collected in a randomised experiment. PARTICIPANTS: 2237 participants with rotator cuff-related shoulder pain were randomly assigned to receive three forms of education: best practice education, best practice education plus pain science messages and structure-focused education. PRIMARY AND SECONDARY OUTCOMES: After receiving the education, participants answered two questions regarding (1) words or feelings evoked by the education and (2) treatments they felt were needed. RESULTS: 2232 responses for each question were analysed (99.7% response rate). Participants who received best practice education more frequently expressed feelings of unhappiness/frustration. The addition of pain science messages to best practice education resulted in slightly more emotional responses and a greater sense of being validated or cared for. In contrast, participants who received structure-focused education more frequently expressed trust in the clinician's expertise and the need for medication, activity modification, rest, diagnostic imaging, injections and surgery. These participants also less frequently considered exercise as a viable treatment option. CONCLUSION: Participants with rotator cuff-related shoulder pain expressed generally similar emotional responses across groups, with small differences in treatment preferences favouring self-management in the best practice education groups compared with those who received structure-focused education. Those in the best practice education also less frequently reported needing potentially unnecessary treatments (eg, imaging, injections and surgery). TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry (ACTRN12623000197639). 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35254 PhyCARE reporting guidelines for physiotherapy case reports: a consensus-based development? Naqvi, W.M.; Mishra, G.V.; Shaikh, S.Z.; Pashine, A.A.; Romero, E.A.S.; Swaminathan, N.; Jiandani, M.P.; Herrero, P.; Zazulak, B.; Macpherson, C.E.; Goyal, C.; Zadro, J.R.; Sahni, P.; Innocenti, T.; Syed, Z.Q.; Hoogeboom, T.; Kiekens, C. OBJECTIVES: Case reports (CRs) are essential in physiotherapy, yet reporting remains heterogeneous and insufficiently standardised. The 2013 CAse REport (CARE) guideline improves transparency but lacks physiotherapy-specific detail. This study aimed to develop a consensus-driven extension of the CARE reporting guideline to support structured reporting of physiotherapy CRs, encompassing physiotherapy-specific assessments and interventions. DESIGN: An e-Delphi consensus process study following the ACcurate COnsensus Reporting Document (ACCORD) guidelines. SETTING: Online. PARTICIPANTS: Forty-four international experts in physiotherapy practice, research and education, along with six core committee members. METHODS: Experts objectively scored items for relevance (5-point Likert scale) and provided open-ended responses for each item of the drafts. Scores and responses were analysed to facilitate iterative refinement of the Physiotherapy CAse REport (PhyCARE) reporting guidelines. Consensus was predetermined at over 70% agreement. RESULTS: Round 1 had the majority of items achieving ?70% agreement, except two items that did not meet the threshold were revised and replaced with an alternative. Five new items addressing physiotherapy-specific reporting needs were added, and 10 items were relocated. In round 2, all 35 items across 13 domains achieved 84%-100%?agreement. The nomenclature of one domain was revised to 'Outcomes and Follow-up'. Following two e-Delphi rounds, consensus was achieved, and suggestions from online meeting, piloting led to item rephrasing, after which the PhyCARE guidelines were finalised. CONCLUSION: The PhyCARE guidelines have the potential to provide a physiotherapy-specific extension of CARE to support structured, transparent and reproducible reporting of physiotherapy CRs. 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35251 The feasibility of delivering and evaluating stratified care integrated with telehealth ('Rapid Stratified Telehealth') for patients with low back pain: a feasibility and pilot randomised controlled trial Gamble, A.R.; Needs, C.; Maher, C.G.; McKay, M.J.; Anderson, D.B.; Hutton, J.M.; Campos, T.F.d.; Foster, N.E.; Martens, D.; Coombs, D.M.; Machado, G.C.; Han, C.S.; Zadro, J.R. OBJECTIVES: Establish the feasibility of delivering and evaluating stratified care integrated with telehealth ('Rapid Stratified Telehealth') to reduce waiting times for people with low back pain seeking care at Australian public hospitals. METHODS: We conducted a single-blinded, single site, 2:1 ratio, two-arm parallel feasibility and pilot randomised controlled trial (RCT) with nested qualitative interviews. Usual clinic-based care for low back pain was compared to Rapid Stratified Telehealth which matched the mode and type of care to participant's risk of persistent disabling pain based on the Keele STarT MSK Tool and potential radiculopathy. Key process outcomes include acceptability of the model, intervention fidelity and adherence, appointment details, response, recruitment and consent rates, and missing data. Additional outcomes included waiting time to access care, clinical outcomes, healthcare utilisation, and adverse events. Quantitative outcomes were summarised descriptively. Qualitative data were analysed using thematic analysis. RESULTS: Of 133 people screened, 101 were eligible (76%), and 40 (30%) were randomised (intervention 26, usual care 14). Feasibility targets were met for acceptability, fidelity, and missing data but not met for recruitment, consent, and response rates. Adherence data was uncertain due to poor reporting. Intervention participants waited a median of 13 days less for their first appointment vs. usual care participants (16 days vs. 29 days). Small sample size and differences in baseline characteristics mean additional outcomes should be interpreted with caution. CONCLUSION: This study provides important information to guide modifications to our Rapid Stratified Telehealth model of care and planning of a large multisite RCT across hospital outpatient clinics. Key Points Our new model of care is feasible to deliver and evaluate in a fully powered RCT. No intervention participant was at low risk of persistent disabling pain. More than half of the intervention participants received clinic-based care. 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35252 The Effect of Diagnostic Labels on Treatment Preferences and Beliefs in People With Musculoskeletal Pain. A Systematic Review of Randomized Trials Martin, S.; Smith, M.; Wilson, D.A.; Zadro, J.R.; Ferreira, G.E.; O'Keeffe, M. OBJECTIVE: To assess how different diagnostic labels affect treatment preferences and beliefs in people with musculoskeletal pain. DESIGN: Systematic review of randomized trials. LITERATURE SEARCH: PubMed, Web of Science, MEDLINE, CINAHL, SPORTDiscus, PsycINFO, ClinicalTrials.gov, and the Australian New Zealand Clinical Trials Registry (ANZCTR) (from inception to September 17, 2025). STUDY SELECTION CRITERIA: Randomized trials evaluating the impact of diagnostic labels for musculoskeletal pain on treatment preferences and beliefs. Studies using hypothetical vignettes were eligible. DATA SYNTHESIS: The primary outcomes were patient treatment preferences and beliefs. Due to heterogeneity of labels and accompanying explanations, a narrative synthesis approach was conducted. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Five vignette-based randomized trials involving 7575 participants were included. Risk of bias was rated as low to some concerns across all outcomes. Low-certainty evidence suggested that specific diagnostic labels may increase patient preferences for imaging and surgery and may increase the perceived seriousness of the condition. Non-specific labels may lead to more positive recovery beliefs and reduced perceived need for invasive treatments, and to lower patient satisfaction. The information accompanying these labels (eg, explanations, reassurance) may have influenced outcomes. CONCLUSION: Based on low-certainty evidence, specific diagnostic labels may increase demand for invasive care and foster more negative recovery expectations. Non-specific labels may encourage non-invasive management but can contribute to patient dissatisfaction. J Orthop Sports Phys Ther 2026;56(1):4-15. Epub 3 December 2025. doi:10.2519/jospt.2025.13759. 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35253 Efficacy and Harms of Opioid Analgesics for Acute Pain: Overview of Systematic Reviews and Meta-analyses Mathieson, S.; Zadro, J.R.; Narayan, S.W.; McLachlan, A.J.; Ballantyne, J.C.; Blyth, F.M.; Day, R.O.; Maher, C.G.; McLachlan, H.; Lin, C.C.; Kamper, S.J.; Shaheed, C.A. BACKGROUND: Opioids are commonly prescribed for acute pain. However, there is no overarching synthesis on their efficacy. AIM: We set out to conduct an overview review of the efficacy and harms of opioid analgesics for acute pain. METHODS: Electronic databases were searched until 4 March 2025 without restriction for systematic reviews of randomised trials comparing opioids to placebo/no active treatment for any acute, non-malignant pain condition published since 2010. Screening, extraction and quality assessment were conducted independently by two authors. The primary outcome was pain. Secondary outcomes were adverse events. Data timepoints were immediate (??3 h after administration-primary timepoint), short (>?3 to ??6 h), intermediate (>?6 to ??48 h) and long term (>?48 h). Random effect meta-analyses were conducted. AMSTAR 2 described review quality. Grading of Recommendations Assessment, Development and Evaluation determined evidence certainty. RESULTS: We included 59 reviews. There was high certainty some opioids (morphine, oxycodone, tramadol, papaveretum) reduced acute abdominal pain at immediate term (mean difference [MD] -?18.4, 95% CI -?31.9 to -?5.0) compared with placebo. However, there were no harms data. At immediate term, there was moderate certainty opioids reduced pain including dental surgery (MD -?19.5, 95% CI -?25.0 to -?14.0), and myringotomy (MD -?15.0, 95% CI -?19.6 to -?10.4). However, harms data were only available for dental surgery, finding no increased risk of adverse events. Oral opioids provided only very small pain relief for acute musculoskeletal pain at intermediate term (MD -?8.9, 95% CI -?13.5 to - 4.3; moderate certainty) but increased the risk of adverse events (risk difference [RD] 0.1, 95% CI 0.0 to 0.2; moderate certainty). LIMITATIONS: Some opioids are not consistently efficacious across timepoints. CONCLUSIONS: Opioid analgesics are efficacious in reducing pain in some acute conditions. REGISTRATION: ROSPERO CRD42018109733. 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35250 Development and acceptability of a patient decision aid for people with degenerative cervical myelopathy: an international mixed-methods study Gamble, A.R.; Anderson, D.B.; McKay, M.J.; Davies, B.; Macpherson, S.; Gelder, J.V.; Hoffmann, T.; McCaffery, K.; Stevens, S.X.; Ammendolia, C.; Chauhan, R.V.; Zipser, C.M.; Boerger, T.F.; Tetreault, L.A.; Fehlings, M.G.; Dustan, E.; Nugent, C.; Holmgren, H.; Demetriades, A.K.; Lantz, J.M.; Dhillon, R.; Maher, C.G.; Zadro, J.R. OBJECTIVES: To develop and user-test a patient decision aid for people diagnosed with degenerative cervical myelopathy and who are considering surgery. DESIGN: Mixed-methods study describing the development of a patient decision aid. SETTING: A draft decision aid was developed by a multidisciplinary steering group (including study authors with degenerative cervical myelopathy, health professionals and researchers) informed by the best available evidence, authorship consensus and existing patient decision aids. PARTICIPANTS: Patient-participants and health professional-participants who manage people with degenerative cervical myelopathy were recruited through social media and the steering group's research and practice network. Quantitative questionnaires were used to gather baseline data, descriptive feedback, refine the decision aid and assess its acceptability. Qualitative semi-structured interviews were conducted online to gather feedback on the decision aid and were analysed using reflexive thematic analysis. RESULTS: We conducted 32 interviews: 19 patient-participants and 13 health professional-participants who manage people with degenerative cervical myelopathy (neurosurgeons, neurologists, physiotherapists, orthopaedic surgeons, general practitioners, rehabilitation and pain specialists and consultant occupational physicians and chiropractors). Participants were from 10 countries (Australia, Canada, Cyprus, Germany, Ireland, New Zealand, Sweden, Switzerland, United Kingdom and USA). Most participants rated the decision aid's acceptability as good-to-excellent and agreed with most aspects of the decision aid (eg, defining degenerative cervical myelopathy, management recommendations, potential benefits and harms, questions to consider asking a health professional). CONCLUSION: Our patient decision aid was rated as an acceptable tool by both health professional-participants who treat degenerative cervical myelopathy and patient-participants with lived experience of degenerative cervical myelopathy. This decision aid can be used by clinicians and people with degenerative cervical myelopathy to help with shared decision making following a diagnosis of degenerative cervical myelopathy. A study testing the potential benefits of this decision aid in a clinical setting is recommended. 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35247 Appraisal of Clinical Practice Guideline: Commonly used interventional procedures for non-cancer chronic spine pain Zadro, J.R. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35249 Co-Designing the Early Pain Intervention After Knee Replacement (EPIK) Model of Care for People With Persistent Pain After Knee Replacement Chadha, N.; Zadro, J.R.; Adie, S.; Tchan, M.; Harris, I.A.; Ackerman, I.N.; Jenkin, D.E.; Dear, B.F.; Maher, C.G.; Buchbinder, R.; Billot, L.; Cameron, I.D.; Gregson, T.; Luck, B.; Ferreira, G.E. BACKGROUND: Approximately one in five Australians who undergo total knee replacement (TKR) experience persistent postoperative pain. There are currently no known effective and cost-effective multidisciplinary models of care in Australia to address this. We are developing the 'Early Pain Intervention after Knee Replacement' (EPIK) model of care, adapted from 'Support and Treatment After Replacement' (STAR) care pathway. STAR was developed in the United Kingdom (UK) and shown to be effective and cost-effective in the UK context. Extensive consumer and clinician engagement informed the development of the EPIK model of care, tailored to the Australian health system and geographical context to address this critical gap. OBJECTIVE: To co-design the 'Early Pain Intervention after Knee replacement' (EPIK) model of care for people with persistent pain after TKR. METHODS: We used Experience-Based Co-Design (EBCD) methodology to co-design EPIK, a telehealth model of care providing remote care coordination for people with persistent pain after TKR. Three online Zoom workshops were conducted with key stakeholders, including consumers with lived experience, clinicians (orthopaedic surgeons, physiotherapists, general practitioners, psychologists and a rehabilitation physician), and EPIK investigators. Workshop 1 explored consumer perspectives on the EPIK model of care assessment and follow-up. Workshop 2 determined the feasibility and roles of clinicians in the EPIK model of care delivery. Workshop 3 brought together consumers, clinicians, and researchers to refine and finalise the EPIK model of care. Using EBCD methodology and inductive framework analysis, themes were derived iteratively. Across consumer and clinician workshops, consensus was reached through facilitated discussions where stakeholders actively contributed to prioritisation activities and iterative refinement of model components. RESULTS: Twenty-one individuals participated in the workshops, comprising nine consumers and 12 clinicians from the Australian Capital Territory, New South Wales, Tasmania, and Western Australia, alongside five EPIK Investigators. Workshop 1 with consumers highlighted the need for clearer definition of communication processes, patient education and coaching strategies, and the role of the EPIK care coordinator to ensure consistent information and coordinated support throughout the model of care delivery. Workshop 2 with clinicians focused on telehealth assessments, escalation of clinical pathways, referrals, and psychological support. The final workshop reached consensus on its components and delivery, emphasising the importance of patient advocacy, reassurance and continuity of personalised care. CONCLUSION: Through meaningful end-user involvement, co-design informed the development of the EPIK model of care. The effectiveness, cost-effectiveness and safety of EPIK will be evaluated in a randomised controlled trial. PATIENT OR PUBLIC CONTRIBUTION: Two consumer co-authors (T.G. and B.L.) guided the development of the preliminary model of care and trial protocol. Consumers with lived experience of persistent pain after TKR participated throughout the co-design process. TRIAL REGISTRATION: ACTRN12625001029482p (Australian and New Zealand Clinical Trials Registry). Registered on 17 September 2025. 2026-01-01T00:00:00Z https://hdl.handle.net/2123/35248 The effectiveness of education for people with shoulder pain: A systematic review Zhang, Z.; Ferreira, G.E.; Downes, J.S.; Cockburn, J.V.; Burke, W.J.; Malliaras, P.; Filho, L.F.S.; Maher, C.G.; Zadro, J.R. OBJECTIVES: To investigate the effectiveness of education for people with shoulder pain. DESIGN: Systematic review LITERATURE SEARCH: We searched several databases (e.g. MEDLINE, EMBASE, CENTRAL, CINAHL) and trial registries from inception to May 25, 2023. STUDY SELECTION CRITERIA: Randomised controlled trials investigating any education for people with shoulder pain. DATA SYNTHESIS: Pain and disability were primary outcomes. The Physiotherapy Evidence Database (PEDro) scale was used to assess methodological quality. Meta-analysis was not appropriate due to heterogeneity. RESULTS: We included 14 trials (8 had high methodological quality). The one trial on rotator-cuff related shoulder pain did not assess pain or disability but found best practice education (vs. structure-focused education) increased reassurance and intentions to stay active. The one trial on adhesive capsulitis found daily reminders, encouragement, and education about exercise via text did not improve pain and disability compared to no education. For post-operative shoulder pain, two (of four) trials found education reduced some measure of pain, but none found an effect on disability or any other outcomes. For 'shoulder complaints' (i.e. mixed or unclear diagnosis), no trials found education was more effective than home exercise or no education for improving pain or disability. CONLUSION: Some forms of education appear to improve reassurance, treatment intentions, perceived treatment needs, recovery expectations, and knowledge, but their effect on pain and disability is unclear. High-quality trials are needed to resolve uncertainty surrounding the benefit of education for shoulder pain, particularly rotator-cuff related shoulder pain and adhesive capsulitis. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35246 Mapping the Choosing Wisely campaigns in physical therapy: Are we missing an opportunity to reduce low-value care? Yi, L.C.; Zadro, J.R.; Soares, R.J.; Meziat-Filho, N.; Reis, F.J.J. BACKGROUND: The Choosing Wisely campaign (CWC) aims to reduce low-value care by encouraging healthcare professionals and patients to discuss unnecessary tests and treatments. While this campaign has been adopted in various medical fields, its implementation in physical therapy is still emerging. OBJECTIVES: To (i) identify physical therapy associations participating in the CWC and (ii) characterize the content of their recommendations. METHODS: We identified physical therapy associations affiliated with World Physiotherapy and conducted a search on their websites or contacted them via email to identify existing Choosing Wisely recommendations. The identified recommendations were categorized into musculoskeletal, neurology, cardiorespiratory, women's health, and mixed themes. RESULTS: Out of 127 physical therapy associations, seven (5.5 %) had Choosing Wisely recommendations, representing associations from Brazil, the USA, Norway, Italy, Australia, Spain, and Switzerland. We identified 62 recommendations, with the majority (48.4 %) related to musculoskeletal physical therapy, followed by mixed themes (27.4 %), women's health (14.5 %), cardiorespiratory (6.4 %), and neurology (3.2 %). CONCLUSION: The adoption of the Choosing Wisely campaign among physical therapy associations appears to be limited. Most recommendations focus on musculoskeletal physical therapy, indicating an opportunity for broader engagement with the campaign. Efforts to promote awareness and adoption of this campaign is needed to support evidence-based practices and reduce low-value care in physical therapy. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35243 Social Media Posts About Medical Tests With Potential for Overdiagnosis Nickel, B.; Moynihan, R.; Gram, E.G.; Copp, T.; Taba, M.; Shih, P.; Heiss, R.; Gao, M.; Zadro, J.R. IMPORTANCE: Social media is an influential source of medical information, but little is known about how posts discuss medical tests that carry potential for overdiagnosis or overuse. OBJECTIVE: To investigate how social media posts discuss 5 popular medical tests: full-body magnetic resonance imaging, the multicancer early detection test, and tests for antimullerian hormone, gut microbiome, and testosterone. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study assessed posts on Instagram and TikTok between April 30, 2015, and January 23, 2024, that discussed full-body magnetic resonance imaging, the multicancer early detection test, and tests for antimullerian hormone, gut microbiome, and testosterone. Using keywords on newly created accounts, posts were searched and screened until 100 posts for each test on each platform were identified (n?=?1000). Posts were excluded if they did not discuss 1 of the 5 tests or were not in English or if the account holders had fewer than 1000 followers. MAIN OUTCOMES AND MEASURES: The main outcome was information about benefits, harms, and overall tone discussed in the post. All outcomes were summarized descriptively. Logistic regression was used to assess whether the use of evidence or the account holder being a physician or having financial interests influenced how tests were discussed. RESULTS: A total of 982 posts from account holders with a combined 194?200?000 followers were analyzed. Across all tests, benefits were mentioned in 855 posts (87.1%) and harms in 144 (14.7%), with 60 (6.1%) mentioning overdiagnosis or overuse. Overall, 823 posts (83.8%) had a promotional (vs neutral or negative) tone. Evidence was explicitly used in 63 posts (6.4%), personal anecdotes were used in 333 (33.9%), 498 posts (50.7%) encouraged viewers to take action and get the test, and 668 account holders (68.0%) had financial interests. Posts from physicians were more likely to mention harms (odds ratio, 4.49; 95% CI, 2.85-7.06) and less likely to have an overall promotional tone (odds ratio, 0.53; 95% CI, 0.35-0.80). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of social media posts about 5 popular medical tests, most posts were misleading or failed to mention important harms, including overdiagnosis or overuse. These data demonstrate a need for stronger regulation of misleading medical information on social media. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35245 What are people's perspectives on different labels for neck pain after a motor vehicle crash? A content analysis of randomized study data Xie, Y.; Mescouto, K.; Liimatainen, J.; Zadro, J.R.; Andersen, T.; Curatolo, M.; Grant, G.; Jull, G.; Kasch, H.; MacDermid, J.; Malmström, E.M.; Ravn, S.L.; Rebbeck, T.; Söderlund, A.; Treleaven, J.; Westergren, H.; Sterling, M. BACKGROUND: Labels for neck pain after a motor vehicle crash (MVC) influenced recovery expectations and management preferences. Research is needed to understand why these expectations and preferences varied based on the label given. AIM: To explore how people perceive different labels for neck pain after an MVC. METHODS: We performed a content analysis of qualitative data from a randomised controlled study. 2229 participants with and without neck pain read a vignette describing a patient with neck pain after an MVC, using one of five labels: whiplash injury, whiplash-associated disorder, post-traumatic neck pain, neck pain, or neck strain. Participants provided free-text responses on the label's meaning, associated words/feelings, required health services/treatments, and any confusion about the label. RESULTS: Compared to neck strain, post-traumatic neck pain, whiplash-associated disorder, and neck pain more commonly evoked negative feelings about symptom severity and prognosis (4.7 % for neck strain versus 7.2 %-16.0 % for other labels) and psychological distress (7.3 % versus 13.0 %-30.3 %). Regarding treatment preference, neck pain most commonly promoted need for passive physical therapies (21.6 %) and imaging (9.8 %), whereas neck strain most often promoted need for exercise (11.6 %) and rarely imaging (3.4 %). Neck pain was the most confusing label (39.9 %), while whiplash injury was the least (14.8 %), with confusion arising from vagueness or a mismatch with diagnostic expectations. CONCLUSION: The meanings, feelings and confusions evoked by neck pain labels after an MVC may explain their impact on recovery expectations and management preferences. Clinicians may consider avoid labels associated with negative feelings and lower preferences for guideline-recommended treatments. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35244 The smallest worthwhile effect of surgery versus non-surgical treatments for sciatica: a benefit-harm trade-off study Salame, A.; Ferreira, M.L.; Hansford, H.J.; Maher, C.G.; Zadro, J.R.; Lin, C.W.C.; Diwan, A.; McAuley, J.H.; Hancock, M.J.; Harris, I.A.; Ferreira, G.E. QUESTION: What is the smallest worthwhile (SWE) effect of discectomy compared with non-surgical treatments amongst people with sciatica? DESIGN: Benefit-harm trade-off study. PARTICIPANTS: People with sciatica of any duration living in Australia and recruited through social media. OUTCOME: The outcome of interest was leg pain intensity. Participants were asked to nominate the additional percentage reduction in leg pain from discectomy--above the reduction anticipated from non-surgical treatments--that would make discectomy worthwhile for them. The SWE was estimated as the median (IQR) of the smallest percentage reduction in leg pain with discectomy (compared with non-surgical treatment) that participants considered worthwhile. The SWE was estimated for the overall sample and those with acute (? 6 weeks), subacute (> 6 to 12 weeks) and chronic (> 12 weeks) sciatica, and investigated factors associated with the SWE. RESULTS: Two hundred participants with a mean age of 59 years (SD 12) were included. The SWE was estimated to be an additional 15% (IQR 10 to 40) reduction in leg pain with discectomy, beyond any reduction in leg pain achieved by non-surgical treatments. Dissatisfaction with previous non-surgical treatments and low pain self-efficacy were associated with smaller SWE estimates. CONCLUSION: People with sciatica would require discectomy to provide an additional 15% reduction in their leg pain beyond the expected 50% improvement in leg pain from non-surgical treatments in the short term to consider discectomy worthwhile. These results can inform the interpretation of the effects of discectomy in randomised trials and meta-analysis from the perspective of consumers. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35240 Do infographics 'spin' the findings of health and medical research? Muller, R.; Ferreira, G.; Bejarano, G.; Gamble, A.R.; Kirk, J.; Sindone, J.; Zadro, J.R. OBJECTIVE: To compare the prevalence of 'spin', and specific reporting strategies for spin, between infographics, abstracts and full texts of randomised controlled trials (RCTs) reporting non-significant findings in the field of health and medicine and to assess factors associated with the presence of spin. DESIGN: Cross-sectional observational study. DATA SOURCE: Publications in top quintile health and medical journals from August 2018 to October 2020 (Journal Citation Reports database). ELIGIBILITY CRITERIA: Infographics, abstracts and full texts of RCTs with non-significant results for a primary outcome. MAIN OUTCOMES AND MEASURES: Presence of spin (any spin and spin in the results and conclusions of infographics, abstracts and full texts). EXPOSURES: Conflicts of interest, industry sponsorship, trial registration, journal impact factor, spin in the abstract, spin in the full text. RESULTS: 119 studies from 40 journals were included. One-third (33%) of infographics contained spin. Infographics were not more likely to contain any spin than abstracts (33% vs 26%, OR 1.4; 95%?CI 0.8 to 2.4) or full texts (33% vs 26%, OR 1.4; 95%?CI 0.8 to 2.4). Higher journal impact factor was associated with slightly lower odds of spin in infographics and full texts, but not abstracts. Infographics, but not abstracts or full texts, were less likely to contain spin if the trial was prospectively registered. No other significant associations were found. CONCLUSIONS: Nearly one-third of infographics spin the findings of RCTs with non-significant results for a primary outcome, but the prevalence of spin is not higher than in abstracts and full texts. Given the increasing popularity of infographics to disseminate research findings, there is an urgent need to improve the reporting of research in infographics. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35239 The Clinical Course of Hip and Knee Osteoarthritis in Adults Attending Two Hospital Outpatient Physiotherapy Clinics in NSW: An Evaluation of the Osteoarthritis Chronic Care Program (OACCP) Melman, A.; Menz, F.; Needs, C.; Campos, T.F.d.; Marabani, M.; Bostock, K.; Dick, R.; Hayes, S.; Zadro, J.R.; Machado, G.C.; Maher, C.G. BACKGROUND: Osteoarthritis (OA) affects over 700,000 individuals in NSW, with projections estimating an increase to 1 million by 2030. This has led to a significant rise in joint replacement surgeries and associated healthcare costs. Despite guidelines recommending non-surgical care as first line treatment, many patients remain on surgical waiting lists without accessing these treatments. AIM: The aims of this study were to describe the characteristics and clinical outcomes of people with hip and knee OA attending two Sydney Local Health District (SLHD) Osteoarthritis Chronic Care Program (OACCP) clinics, and to identify whether baseline measures are associated with achieving Minimal Clinically Important (MCI) difference in outcomes. METHODS: This retrospective study (n = 1402) evaluated the OACCP's implementation within two SLHD hospitals between Oct 2018 and Sept 2023, describing patient characteristics, patient reported outcomes, physical performance measures, and allied health access. Changes in clinical outcomes in the short-term (3 months) and long-term (12 months) assessment as well as associations of patient's baseline measures with MCI improvements in clinical outcomes were analysed. RESULTS: Most self-reported outcomes and physical performance measures improved at both 3 and 12 months. 38.6% of patients reached the MCI threshold for KOOS total score at 3 months, which rose to 52.1% at 12 months. None of the baseline characteristics predicted outcomes. CONCLUSION: Following multidisciplinary non-surgical care, people with hip and/or knee OA experience improved quality of life and function that is sustained for up to 12 months. However, analysis was limited by low long-term follow-up rates and no control group. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35242 Equity in Choosing Wisely and beyond: the effect of health literacy on healthcare decision-making and methods to support conversations about overuse Muscat, D.M.; Cvejic, E.; Smith, J.; Thompson, R.; Chang, E.; Tracy, M.; Zadro, J.; Linder, R.; McCaffery, K. OBJECTIVE: To (a) examine whether the effect of the Choosing Wisely consumer questions on question-asking and shared decision-making (SDM) outcomes differs based on individuals' health literacy and (b) explore the relationship between health literacy, question-asking and other decision-making outcomes in the context of low value care. METHODS: Preplanned analysis of randomised trial data comparing: the Choosing Wisely questions, a SDM video, both interventions or control (no intervention). Randomisation was stratified by participant health literacy ('adequate' vs 'limited'), as assessed by the Newest Vital Sign. MAIN OUTCOME MEASURES: Self-efficacy to ask questions and be involved in decision-making, and intention to engage in SDM. PARTICIPANTS: 1439 Australian adults, recruited online. RESULTS: The effects of the Choosing Wisely questions and SDM video did not differ based on participants' health literacy for most primary or secondary outcomes (all two-way and three-way interactions p>0.05). Compared with individuals with 'adequate' health literacy, those with 'limited' health literacy had lower knowledge of SDM rights (82.1% vs 89.0%; 95% CI: 3.9% to 9.8%, p<0.001) and less positive attitudes towards SDM (48.3% vs 58.1%; 95% CI: 4.7% to 15.0%, p=0.0002). They were also more likely to indicate they would follow low-value treatment plans without further questioning (7.46/10 vs 6.94/10; 95% CI: 0.33 to 0.72, p<0.001) and generated fewer questions to ask a healthcare provider which aligned with the Choosing Wisely questions (?(2) (1)=73.79, p<.001). On average, 67.7% of participants with 'limited' health literacy indicated that they would use video interventions again compared with 55.7% of individuals with 'adequate' health literacy. CONCLUSION: Adults with limited health literacy continue to have lower scores on decision-making outcomes in the context of low value care. Ongoing work is needed to develop and test different intervention formats that support people with lower health literacy to engage in question asking and SDM. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35241 Do Italian Physiotherapists Follow Evidence-Based Guidelines When Managing Patients With Low Back Pain? A Cross-Sectional Survey Muller, R.D.; Schut, S.M.; Perna, P.; Ferrara, A.; Banchetto, D.; Zadro, J.R. INTRODUCTION: Guideline-recommended management of low back pain (LBP) is associated with improved patient outcomes and costs. This study aimed to assess Italian physiotherapists' attitudes towards and adherence to LBP clinical practice guidelines (CPGs). METHODS: We conducted an online cross-sectional survey of Italian physiotherapists. Participants' demographics, attitudes towards, and familiarity with CPGs were collected. Six vignettes of patients with LBP were presented. For each, participants selected management options from a pre-specified list. Management options were categorised as recommended, not recommended, and no recommendation based on CPG recommendations and systematic reviews. Ordinal logistic regression assessed associations between participant characteristics and the number of vignettes for which recommended and not recommended care options were selected (stratified by non-specific LBP and red flag vignettes). RESULTS: Of the 272 participants completing the demographic section of the survey, 142 completed all vignettes. Care that was recommended, not recommended, and had no recommendation was selected by 87%, 32%, and 93% of participants on average in the six vignettes, respectively. Working in a hospital setting was associated with a reduced likelihood of selecting recommended care for non-specific LBP (coefficient: -1.28; 95% CI: -2.20, -0.36). Stronger self-reported familiarity with three published CPGs was associated with decreased likelihood of selecting not recommended care but was not associated with selecting recommended care for non-specific LBP. All other variables were not associated with selecting recommended and not recommended care. CONCLUSIONS: Physiotherapists commonly selected recommended care options for patients with LBP, yet there remains considerable scope to reduce selection of care which is not recommended. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35236 Effectiveness of Choosing Wisely recommendations in reducing physiotherapists' intentions to refer for imaging and use electrotherapy for low back pain: a randomised controlled experiment Kharel, P.; Maher, C.G.; Gamble, A.R.; Ferreira, G.E.; Zadro, J.R. QUESTION: What is the effect of Choosing Wisely recommendations on physiotherapists' intentions to refer for imaging and use electrotherapy for low back pain? DESIGN: Three-arm parallel-group online randomised controlled trial. PARTICIPANTS: Physiotherapists who treat people with low back pain. INTERVENTION: Participants were randomised to receive: (a) two original Australian Physiotherapy Association Choosing Wisely recommendations about low back pain, (b) two optimised versions of these recommendations based on previous research and (c) no recommendations. Participants were then directed to read three clinical vignettes of a person with low back pain and respond to questions regarding each vignette. OUTCOME MEASURES: Primary outcomes were physiotherapists' intentions to refer for imaging and use electrotherapy for low back pain. Secondary outcomes were physiotherapists' intentions to use other treatments for low back pain, the influence of the recommendations on decision-making in the vignettes and familiarity with the recommendations. RESULTS: 723 participants opened the survey and 473 (65%) provided complete responses. Across all vignettes, there were no statistically significant differences in intentions to refer for imaging or use electrotherapy between those who received Choosing Wisely recommendations versus no recommendation (imaging ORs ranging from 0.7 (95% CI 0.5 to 1.0) to 0.9 (0.6 to 1.4); electrotherapy ORs ranging from 0.9 (0.5 to 1.7) to 1.1 (0.7 to 2.0)). Similarly, no significant differences were observed between those who received optimised versus original recommendations for all three vignettes. CONCLUSION: Our study suggests simply presenting Choosing Wisely recommendations to physiotherapists does not influence their intentions to refer for imaging or use electrotherapy for low back pain, even if the language of the recommendations is optimised. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35238 Non-specific diagnostic labels for musculoskeletal conditions foster positive views about prognosis and non-invasive management but require clear explanation: a systematic review Martin, S.; Smith, M.; Wilson, D.A.; Zadro, J.R.; Ferreira, G.E.; O'Keeffe, M. QUESTIONS: What are patient and public perceptions of diagnostic labels for musculoskeletal pain? How do these labels influence beliefs, emotions and treatment preferences? DESIGN: Systematic review and qualitative meta-synthesis. PARTICIPANTS: People with musculoskeletal pain or people presented with hypothetical vignettes of musculoskeletal pain. INTERVENTION: Diagnostic labels for musculoskeletal pain. OUTCOME MEASURES: Patient/public perceptions of diagnostic labels for musculoskeletal pain and the influence of these labels on beliefs, emotions and treatment preferences. RESULTS: Four major themes emerged. First, patients strongly valued diagnoses to validate their pain and guide treatment. Second, poor diagnostic explanations and use of medical jargon led to patient frustration and confusion. Third, specific diagnostic labels were validating but promoted fear and a biomedical view of pain, whereas non-specific labels were associated with less fear but higher confusion. Fourth, non-specific labels led to more positive views towards prognosis and non-invasive management but led some patients to believe that further investigations were needed. CONCLUSION: Patients have a strong desire for a diagnosis and may prefer specific diagnostic labels, but these can lead to patient harm. Non-specific labels, while less threatening, require clear explanations to avoid confusion. REGISTRATION: CRD42024592437. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35237 Development of a decision aid for Australian carers of children with cerebral palsy and their community clinicians, about selective dorsal rhizotomy surgery Lewis, J.A.; Stewart, K.; Paget, S.P.; Wimalasundera, N.; Wynter, M.; Zadro, J.R.; Bonner, C.; McKay, M.J. PURPOSE: Develop and user-test a patient decision aid about selective dorsal rhizotomy (SDR) surgery for carers of children with cerebral palsy (CP) and clinicians treating children with CP. METHOD: This study utilised a mixed-methods design. Stage One developed the prototype. Stage Two recruited carers and clinicians to focus groups/semi-structured interviews to review the prototype. Stage Three was an iterative cycle of redrafts based on feedback from Stage Two and input from the SDR Advisory and Consumer Groups. Stage Four assessed acceptability of the SDR Decision Aid via questionnaire. RESULTS: A prototype SDR decision aid was developed and reviewed by 13 clinicians and 8 carers. Five themes were identified: (1) positive and (2) constructive feedback on the presentation; and additional information considered important for future end-users regarding (3) rehabilitation, (4) lived experience, and (5) selection processes. The final version of the SDR Decision Aid was rated highly acceptable by carers and clinicians, based on length, amount of information provided, and usefulness in clinical settings. Participants indicated they would recommend the decision aid to others seeking information about SDR. CONCLUSION: The SDR Decision Aid is an acceptable and valuable tool for helping parents discuss SDR as a treatment option with their clinicians. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35235 A Codesigned Patient Decision Aid Supports the Decision Quality of Patients Considering Total Knee Arthroplasty: A Randomized Controlled Trial Karunaratne, S.; Horsley, M.; Solomon, M.; Trevena, L.; Hoffmann, T.; McCaffery, K.; Zadro, J.; Harris, I.A. BACKGROUND: The primary aim of this study was to evaluate the effectiveness of a codesigned patient-facing decision aid compared to standard care alone for patients making a high-quality, informed decision regarding the decision to undergo total knee arthroplasty (TKA). METHODS: A double-blind, randomized controlled trial was undertaken in a multisurgeon public hospital arthroplasty clinic and private clinics of orthopaedic surgeons in Australia. A total of 216 patients were randomized before seeing an orthopaedic surgeon to either receive standard care or a printed decision aid in addition to standard care. The primary outcome was whether patients made a high-quality decision (defined as patients being knowledgeable of TKA outcomes and choosing a goal-concordant treatment) 2 weeks post-consultation. Secondary outcomes included how much the decision aid helped make a decision, satisfaction with the decision, and decisional conflict. RESULTS: At the 2-week follow-up, the primary outcome was provided by 173 (80.1%) participants. Participants receiving the aid were more likely to make a high-quality decision (odds ratio: 3.72, 95% confidence interval [CI]: 1.77 to 7.83, P < 0.001) and had lower associated decisional conflict using the Decisional Conflict Scale (mean difference: -5.7, 95% CI: -10.9 to -0.5, P = 0.033). Participants receiving the decision aid were more likely to report that they felt informed (mean difference: 2.2, 95% CI: 1.3 to 3.1, P < 0.001). There was no difference in the rate of surgery election or short-term satisfaction with the decision-making process. CONCLUSIONS: The decision aid markedly improved the likelihood of a patient making a high-quality decision and had less decisional conflict. Use of the aid in practice was feasible. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35234 Effectiveness of a physiotherapist-led triage and treatment service on WAITing time for adults with musculoskeletal pain referred to Australian public hospital physiotherapy clinics: a protocol for the WAIT-less trial Hutton, J.M.; Gamble, A.R.; Maher, C.G.; Campos, T.F.d.; Han, C.S.; Coombs, D.; Halliday, M.; Harvey, L.A.; Foster, N.E.; Machado, G.; Anderson, D.; Billot, L.; Richards, B.; Swain, M.; McKay, M.; Needs, C.; Chu, J.; Shaw, T.; Lung, T.; Harris, I.A.; Zadro, J.R. INTRODUCTION: Musculoskeletal pain is the second leading cause of disease burden in Australia, and there is a need to investigate new models of care to cope with the increasing demand for health services. This paper describes the protocol for a randomised controlled trial investigating whether a physiotherapist-led triage and treatment service is non-inferior for improving function at 6?months and superior for reducing treatment waiting times, compared with usual care for patients with musculoskeletal pain referred to public hospital outpatient physiotherapy clinics. METHODS AND ANALYSIS: A total of 368 participants (184 per arm) will be recruited from six public hospitals located in metropolitan Sydney, Australia. We will recruit adult patients newly referred to a public hospital physiotherapy outpatient clinic with a musculoskeletal condition that is typically managed by a physiotherapist (eg, back or neck pain, osteoarthritis, rehabilitation postorthopaedic surgery and sporting injuries). Participants will be randomised 1:1 to the physiotherapist-led triage and treatment service or usual care. A physiotherapist will telephone participants in the intervention group and match them to different modes and types of care based on baseline characteristics. Participants at low risk of poor outcomes (assessed by the Keele STarT MSK tool) will be given simple advice and education during this call and instructed to call back if their symptoms do not improve in 6 weeks. Participants at medium risk of poor outcomes or requiring postoperative rehabilitation will be offered a course of telehealth (videoconference) physiotherapy targeting exercise-based self-management. Participants at high risk of poor outcomes and/or with potential nonprogressive radiculopathy will be offered a course of usual clinic-based physiotherapy as per all participants in the usual care group. Physical function (Patient Specific Functional Scale) at 6 months postrandomisation and waiting time (time from randomisation to first treatment) are coprimary outcomes. Secondary outcomes include other patient outcomes (eg, pain), health resource use, adverse events, process measures (eg, adherence) and costs. ETHICS AND DISSEMINATION: This trial has approval from the Sydney Local Health District Human Research Ethics Committee (RPAH Zone; X24-0090 and 2024/ETH00585). Recruitment will commence in September 2024 and is expected to be completed by December 2025 with follow-ups completed by December 2026. The results of the trial will be submitted for publication in reputable international journals and presented at relevant national and international conferences. TRIAL REGISTRATION NUMBER: ANZCTR (ACTRN12624000947505). 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35232 The smallest worthwhile effect on pain and function for rotator cuff repair surgery: a benefit-harm trade-off study Hansford, H.J.; Buchbinder, R.; Zadro, J.R.; McAuley, J.H.; Ferreira, M.L.; Lewin, A.; Page, R.S.; Harris, I.A. BACKGROUND: The smallest worthwhile effect (SWE) is the minimum benefit required in addition to that from a comparator for an intervention to be considered worthwhile by patients. We aimed to estimate the SWE for rotator cuff repair (with decompression and debridement) compared to either decompression and debridement alone or to non-surgical treatment for people with atraumatic shoulder pain. METHODS: Benefit-harm trade-off study. We recruited English-speaking adults aged 45-75 years with shoulder pain of intensity???4 (on a 0-10 scale) for???6 months to our online survey through paid advertising on Facebook. Participants must have sought care in the past 6 months and could not have had recent shoulder surgery or significant recent shoulder trauma. Participants were explained three treatments: rotator cuff repair (with subacromial decompression and debridement), subacromial decompression and debridement alone, and non-surgical treatment. Participants completed the benefit-harm trade-off survey to determine the SWE of improvements in pain and function for rotator cuff repair compared to the other treatments and again after one week to assess reliability. We used univariable linear regression to estimate associations between baseline characteristics and SWE. RESULTS: We recruited 56 participants. The mean?±?standard deviation age was 58.4?±?6.7 years, and 39 (70%) were female. For rotator cuff repair to be worthwhile compared to decompression and debridement alone, participants needed to see at least a median 40% (interquartile range (IQR) 20-62.5) between-group improvement in pain and function. Compared to non-surgical treatment, the SWE was a median 40% (IQR 30-60). On the Western Ontario Rotator Cuff (WORC) Index, the SWE values equate to a between-group improvement of 28/100 points (533/2100 on the raw WORC score). Female sex was associated with larger SWEs for both comparisons. Reliability analyses were underpowered, 25/56 (45%) provided follow-up data. The intraclass correlation coefficient estimates ranged from 0.60 to 0.77. CONCLUSIONS: This SWE indicates the benefit required by people with shoulder pain to consider the costs and risks of surgical rotator cuff repair worthwhile is larger than previously estimated minimum clinically important differences (13.5-28/100 on the WORC Index). This SWE may be used to inform the design or interpret the findings of trials of these comparisons. TRIAL REGISTRATION: Open Science Framework (osf.io/crj9p). Registered retrospectively on 11/06/2024. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35233 Remotely delivered physiotherapy for musculoskeletal conditions is cost saving for the health system and patients: economic evaluation of the REFORM randomised trial Hayes, A.J.; Withers, H.G.; Glinsky, J.V.; Chu, J.; Jennings, M.D.; Starkey, I.; Parmeter, R.; Boulos, M.; Cruwys, J.J.; Duong, K.; Jordan, I.; Wong, D.; Trang, S.; Duong, M.; Liu, H.; Lambert, T.E.; Zadro, J.R.; Sherrington, C.; Maher, C.; Lucas, B.R.; Taylor, D.; Ferreira, M.L.; Harvey, L.A. QUESTIONS: Is remotely delivered physiotherapy cost saving when compared with usual face-to-face physiotherapy as typically provided in a public hospital outpatient setting? Is remotely delivered physiotherapy cost-effective? DESIGN: Economic evaluation embedded within a randomised controlled, non-inferiority trial using a health system plus patient perspective. PARTICIPANTS: Patients with musculoskeletal conditions presenting to Sydney public hospitals for physiotherapy treatment. INTERVENTION: REFORM was a randomised controlled trial comparing remotely delivered physiotherapy with usual care provided in an outpatient setting. Remotely delivered physiotherapy involved one face-to-face physiotherapy session in conjunction with text messages, phone calls and an individualised exercise program delivered through an 'App'. OUTCOME MEASURES: The economic evaluation included the Patient Specific Functional Scale at 6 weeks in the cost-minimisation and cost-effectiveness analyses, and quality-adjusted life years (QALYs) at 26 weeks in the cost-utility analysis. Health system and patient resource use were derived from patient self-report. RESULTS: Costs per participant over 6 weeks were AUD $742 for remotely delivered physiotherapy and $910 for face-to-face physiotherapy, with a mean cost difference of -$168 (95% CI -$339 to $1). There was a 98% probability of remotely delivered physiotherapy being cost saving within the non-inferiority margin of the Patient Specific Functional Scale, and an 88% probability of being dominant to face-to-face physiotherapy (less costly and more effective). There was a 51% probability of being cost-effective at a nominal $50,000/QALY threshold. CONCLUSION: Moving people with musculoskeletal conditions to a remote model of physiotherapy care is potentially cost saving for health systems and patients, without compromising health outcomes when compared with currently provided public hospital care. TRIAL REGISTRATION: ACTRN12619000065190. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35230 Management of musculoskeletal conditions with remotely delivered physiotherapy versus face-to-face physiotherapy: process evaluation of the REFORM trial using the Realist Evaluation and the RE-AIM Framework Chu, J.; Withers, H.G.; Glinsky, J.V.; Liu, H.; Jennings, M.D.; Starkey, I.J.; Palmer, B.; Parmeter, R.; Cruwys, J.J.; Boulos, M.; Jordan, I.; Duong, M.; Duong, K.; Wong, D.; Lambert, T.E.; Lucas, B.R.; Taylor, D.; Maher, C.G.; Sherrington, C.; Zadro, J.R.; Harvey, L.A. OBJECTIVES: The objectives of this process evaluation were to explain the results of the REFORM (REhabilitation FOR Musculoskeletal conditions) trial and identify potential facilitators and barriers to the future rollout of a remotely delivered physiotherapy model of care. SETTING: Outpatient physiotherapy units in five government-funded public hospitals in Sydney, Australia. DESIGN: This process evaluation was run alongside the REFORM trial. The REFORM trial (n=210) set out to determine whether remotely delivered physiotherapy (with one initial face-to-face session with a physiotherapist) was as good or better than a course of face-to-face physiotherapy. The process evaluation was informed by The UK Medical Research Council Process Evaluation Guidance. It was also based on the Realist Evaluation and the dimensions of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Framework. Qualitative and quantitative data were collected. The qualitative data included semistructured interviews. The quantitative data included audits of screening logs and participants' self-reported satisfaction with service delivery. A thematic analysis using both inductive and deductive approaches was used for qualitative analysis. Multiple data were used to triangulate the process evaluation findings. PARTICIPANTS: Quantitative data were collected on 210 participants. Qualitative interviews were conducted with 20 participants, 15 physiotherapists and 5 stakeholders. RESULTS: Some participants valued the convenience and accessibility of remotely delivered physiotherapy. It was also deemed to have the potential of improving the efficiency in the way physiotherapy is delivered. The findings from the RE-AIM framework were mixed. For example, the Reach was limited, and the Adoption and Maintenance were inconsistent across sites. CONCLUSION: Remotely delivered physiotherapy has the potential to be rolled out across Australian clinical settings to participants similar to the REFORM trial. However, further research involving participants with different types and severity of musculoskeletal conditions is needed to improve the generalisability of our findings. Adoption might be improved with a hybrid model of care where physiotherapists' and patients' preferences are met. TRIAL REGISTRATION NUMBER: ACTRN12619000065190. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35231 Traumatic knee injury healthcare pathways and outcomes: the Australian Knee Injury Inception Cohort Study (KIICS) protocol Dubé, M.O.; Crossley, K.M.; Bruder, A.M.; Patterson, B.E.; Kaplan, S.; Haberfield, M.J.; Barton, C.J.; Filbay, S.R.; Dowsey, M.M.; Docking, S.I.; Zadro, J.R.; Ackerman, I.N.; Kvist, J.; Pappas, E.; Moselen, T.; Culvenor, A.G. Decision-making for the optimal management of traumatic knee injuries can be challenging. Clinical trials reveal only small differences between surgical and non-surgical approaches, while patient and clinician biases, as well as healthcare access issues, may also influence management. Little is known about the real-world healthcare pathways for patients with a knee injury, as well as the person- and/or healthcare-related factors that influence management strategies and outcomes. The Australian Knee Injury Inception Cohort Study (KIICS) aims to: (1) describe healthcare pathways following acute knee injury (including the timing and type of healthcare consultations); (2) identify patient- and/or healthcare-related predictors of management strategy (ie, surgical vs non-surgical); and (3) examine the long-term outcome of different injury types, healthcare pathways and management strategies. KIICS is a nationwide prospective longitudinal inception cohort study recruiting Australians who have sustained an acute knee injury within the previous 6 months that disrupted daily activities or sports and led to a healthcare consultation. Participants will complete online questionnaires at enrolment and at 6 months, 1, 2, 5 and 10 years post-injury. The data to be collected will include sociodemographic characteristics, knee injury history, the sequence of healthcare consultations and referral patterns, and management strategies (ie, surgical vs non-surgical). Patient-reported outcomes will include knee pain and instability, knee-related quality of life, patient-acceptable symptom state, health-related quality of life, mental health, fear of reinjury, return-to-sport status and activity level. Detailed statistical analysis plans will be developed to address the study's key research questions, informing clinical practice, shared decision-making and healthcare policy. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35229 Development of a patient decision aid for people with chronic low back pain and degenerative disc disease considering lumbar fusion: A mixed-methods study Cho, Y.; McKay, M.J.; Zadro, J.R.; Hoffmann, T.; Maher, C.G.; Harris, I.; Stanford, R.; Ferreira, M.L.; Buchbinder, R.; Han, C.S.; Ferreira, G.E. OBJECTIVES: To develop and user-test a patient decision aid providing evidence-based information for people with chronic low back pain (LBP) and degenerative disc disease considering lumbar fusion. DESIGN: Convergent parallel mixed methods study. SETTING: A prototype patient decision aid was developed, guided by the International Patient Decision Aid Standards (IPDAS) criteria, a multidisciplinary steering committee, and insights from previous studies. Participants were recruited via social media and the authors' collaborative networks to refine and evaluate the decision aid. PARTICIPANTS: Individuals who underwent lumbar fusion for chronic LBP and health professionals who manage these patients were purposively sampled. PRIMARY AND SECONDARY OUTCOMES: Semi-structured interviews and questionnaires were used to gather feedback and assess the decision aid's acceptability, usability, and preparedness for decision-making. Framework analysis was used for interview data and descriptive analysis for questionnaires. RESULTS: Sixteen clinicians (5 physiotherapists, 2 rheumatologists, 2 surgeons, 7 general practitioners) and seven patients participated, most rating the prototype's acceptability as 'excellent' or 'good'. Usability (mean [SD], health professionals: 78 [16], patients: 72 [8]) and preparedness for decision-making (health professionals: 73 [14], patients: 72 [10]) also scored highly. However, some viewed the prototype as biased against lumbar fusion, and suggestions to include more personalised information were made. CONCLUSIONS: This study showed that our prototype patient decision aid is acceptable, useful, and prepares patients to make informed decisions about spinal fusion for chronic LBP and degenerative disc disease. Future studies will assess the clinical impact of our decision aid and its optimal distribution timing. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35228 Exploring the decisional needs of patients living with subacromial pain syndrome: A qualitative needs assessment study Bengtsen, S.C.; Zadro, J.R.; Rathleff, M.S.; Foster, N.E.; Thomsen, J.L.; Olesen, J.L.; Søndergaard, J.; Lyng, K.D. BACKGROUND: There are a variety of different treatments for patients living with subacromial pain syndrome (SAPS). All treatments have small to moderate effect sizes, and it is challenging when healthcare practitioners and patients need to decide on which treatment options to choose. The aim of this study was to explore and understand the decisional needs of patients with SAPS, to inform and support the decision-making process. METHODS: A qualitative research study, using semi-structured individual interviews with patients with SAPS. The interview guide was informed by the Ottawa Decision Support Framework (ODSF), previous research related to treatment decision-making, other decisional needs assessment studies, and inputs from patients with SAPS and healthcare practitioners. Data were analysed by using reflexive thematic text analysis and ODSF. The analysis was conducted in NVivo 12. RESULTS: We invited 22 participants of which 17 (age 22-71 years) took part in the study. We found three main themes related to individual decisional needs in the context of decision-making: 1) The necessity of certainty and adequate information as fundamental prerequisites for effective decision-making, 2) The importance of person-centered care to achieve a desirable decision, and 3) The need for a supportive environment to facilitate adaptation and acceptance of the decision. CONCLUSION: The decision-making process faced by patients with SAPS is complex and involves several decisional needs. Our findings highlight the importance of healthcare professionals identifying and addressing patients' decisional needs in consultations with patients with SAPS. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35225 Is It Time to Reframe How Health Care Professionals Label Musculoskeletal Conditions? Zadro, J.R.; O'Keeffe, M.; Ferreira, G.E. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35226 Exploring physiotherapist's ability to identify cauda equina syndrome early Althobaiti, K.F.; Zadro, J.R.; Alzhrani, F.A.; Alzahrani, H.A. OBJECTIVES: To explore the ability of physiotherapists in Saudi Arabia to identify cauda equina syndrome (CES) in a timely manner, and to identify the methods used by physiotherapists to manage patients with suspected CES. METHODS: This study utilized a cross-sectional research design and was conducted in the period May-October 2023. It included licensed physiotherapists working in Saudi Arabia. The data was collected using a survey that aimed to assess physiotherapists' ability to identify CES early, using 12 statements. Based on the participants response to these statements, all responders were categorized into the following groups based on their ability to identify and manage CES early: proficient (10-12 points); good ability (7-9); fair ability (5-6); and poor ability (<=4). Consensus to a statement was reached when more than 70% of participants agreed or disagreed with the statement. RESULTS: This study included 401 physiotherapists (mean age=29.51 (SD 5.54); 53.4% female). Most participants (63.6%) have a proficient-good ability to identify and manage CES early, while 36.4% were categorized as having fair-poor ability Consensus for the CES statements was achieved for 8 statements [1, 2, 3, 4, 5, 8, 9, 12] out of 12. Among these statements, most participants agreed that a patient should be suspected to have CES when they exhibited urinary difficulties of neurogenic origin (88.3%) and/or bilateral radiculopathy (85.5%); and 88.0% of them agreed that an MRI should be requested urgently when managing a patient with CES. Conversely, consensus was not achieved on statements, concerning communication with patients, patient instructions, and management decisions for suspected CES cases. CONCLUSION: Most physiotherapists had a proficient-good ability to identify and manage CES early. The study's findings can aid in the creation or improvement of clinical standards and protocols pertaining to physiotherapists' roles in the early identification of CES. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35224 Development of the Reporting Infographics and Visual Abstracts of Comparative studies (RIVA-C) checklist and guide Zadro, J.R.; Ferreira, G.E.; Stahl-Timmins, W.; Egger, V.; Elkins, M.R.; Gamble, A.R.; O'Keeffe, M.; McCaffery, K.J.; Harris, I.A.; Ardern, C.L.; West, C.A.; Maher, C.G.; Hoffmann, T.C. People often use infographics (also called visual or graphical abstracts) as a substitute for reading the full text of an article. This is a concern because most infographics do not present sufficient information to interpret the research appropriately and guide wise health decisions. The Reporting Infographics and Visual Abstracts of Comparative studies (RIVA-C) checklist and guide aims to improve the completeness with which research findings of comparative studies are communicated and avoid research findings being misinterpreted if readers do not refer to the full text. The primary audience for the RIVA-C checklist and guide is developers of infographics that summarise comparative studies of health and medical interventions. The need for the RIVA-C checklist and guide was identified by a survey of how people use infographics. Possible checklist items were informed by a systematic review of how infographics report research. We then conducted a two-round, modified Delphi survey of 92 infographic developers/designers, researchers, health professionals and other key stakeholders. The final checklist includes 10 items. Accompanying explanation and both text and graphical examples linked to the items were developed and pilot tested over a 6-month period. The RIVA-C checklist and guide was designed to facilitate the creation of clear, transparent and sufficiently detailed infographics which summarise comparative studies of health and medical interventions. Accurate infographics can ensure research findings are communicated appropriately and not misinterpreted. By capturing the perspectives of a wide range of end users (eg, authors, informatics editors, journal editors, consumers), we are hopeful of rapid endorsement and implementation of RIVA-C. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35227 Impact of a Decision Aid on Perceptions of Shared Decision-Making in the Primary Care Management of Patients With Subacromial Pain Syndrome: A Two-Phased Multi-Methods Study Bengtsen, S.C.; Rathleff, M.S.; Zadro, J.R.; Olesen, J.L.; Foster, N.E.; Thomsen, J.L.; Elwyn, G.; Søndergaard, J.; Lyng, K.D. BACKGROUND: Subacromial pain syndrome (SAPS) is the most common shoulder pain condition in primary care. Despite the importance of shared decision-making (SDM) being increasingly recognised, its application in SAPS care remains poorly understood. The primary aim of this study was to explore the influence of a decision aid on patient and observer perceptions of SDM, and secondarily to explore correlations between these ratings in the primary care management of patients with SAPS. METHODS: We conducted a multi-methods study including observations of consenting patients with SAPS in their clinical consultations with clinicians from four Danish primary care practices using OPTION-12. We gathered patients' perceptions of SDM 2 weeks after the consultation using the CollaboRATE questionnaire and Shared Decision-Making Questionnaire (SDM-Q-9). We observed consultations with and without the introduction of a decision aid tailored to support the management of patients. RESULTS: Thirty-four consultations were observed (16 with and 18 without the decision aid). Without the aid, the mean (SD) OPTION-12 score was 10.5 (3.3), while the median (IQR) CollaboRATE and mean (SD) SDM-Q-9 scores were 5 (1.3) and 22.2 (7.5), respectively. With the aid, scores significantly increased: OPTION-12 to 22.7 (6.87, range 5-32), CollaboRATE to 6.5 (1.4), and SDM-Q-9 to 30.6 (8.4). Patients' and observers' OPTION-12 and SDM-Q-9 scores correlated significantly across both phases, but no significant correlation was found between CollaboRATE, OPTION-12, and SDM-Q-9 scores in either phase. CONCLUSION: A decision aid significantly improved observer- and patient-rated SDM in primary care consultations for patients with SAPS. Observer-rated SDM scores more than doubled with the decision aid, and patients reported higher levels of SDM. 2025-01-01T00:00:00Z https://hdl.handle.net/2123/35221 The Influence of "Labels" for Neck Pain on Recovery Expectations Following a Motor Vehicle Crash: An Online-Randomized Vignette-Based Experiment Xie, Y.; Costa, N.; Söderlund, A.; Zadro, J.; Malmström, E.M.; Grant, G.; Jull, G.; Westergren, H.; Kasch, H.; MacDermid, J.; Treleaven, J.; Curatolo, M.; Ravn, S.L.; Andersen, T.; Rebbeck, T.; Sterling, M. OBJECTIVES: To (1) investigate whether different labels for neck pain after a motor vehicle crash (MVC) influenced recovery expectations and management beliefs, (2) explore reasons for low recovery expectations and greater likelihood for lodging a claim, and (3) explore the moderating effect of neck pain history and sociodemographic characteristics. DESIGN: Online randomized experiment with nested qualitative content analysis. METHODS: We randomized 2229 participants from the general population (mean age: 46.7 ± 17.5 years; 72.4% females; 66% with previous or current neck pain; 10% with an MVC experience) to read 1 of 5 scenarios describing a patient with neck pain after an MVC, each was labeled as whiplash injury, whiplash-associated disorder, posttraumatic neck pain, neck pain, or neck strain. The primary outcome was recovery expectations, rated on a 0- to 10-point scale. RESULTS: Participants allocated to whiplash-associated disorder or neck pain had lower recovery expectations than those allocated to neck strain (adjusted mean difference [95% confidence interval]: -0.5 [-0.9 to -0.1] for both comparisons). Whiplash-associated disorder led to more recovery uncertainty, while neck pain led to greater doubt about the health care provider. Most secondary outcomes showed significant but small differences. Participants allocated to neck strain were less inclined to claim than those allocated to whiplash-associated disorder or whiplash injury due to less perceived need for financial support. Neck pain history moderated labeling effects on recovery expectations; household income moderated the claim intention. CONCLUSIONS: Labels for neck pain after an MVC influenced recovery expectations and management preferences. The clinical relevance of the small effects was unclear. J Orthop Sports Phys Ther 2024;54(11):1-10. Epub 5 September 2024. doi:10.2519/jospt.2024.12590. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35223 Education can reassure people with rotator cuff-related shoulder pain: a 3-arm, randomised, online experiment Zadro, J.R.; Ferreira, G.E.; Muller, R.; Filho, L.F.S.; Malliaras, P.; West, C.A.; O'Keeffe, M.; Maher, C.G. We aimed to investigate the immediate effect of best practice education (with and without pain science messages) and structure-focused education on reassurance among people with rotator cuff-related shoulder pain. We conducted a 3-arm, parallel-group, randomised experiment. People with rotator cuff-related shoulder pain were randomised (1:1:1) to (1) best practice education (highlights that most shoulder pain is not serious or a good indicator of tissue damage and recommends simple self-management strategies); (2) best practice education plus pain science messages (which attempt to improve understanding of pain); and (3) structure-focused education (highlighting that structural changes are responsible for pain and should be targeted with treatment). Coprimary outcomes were self-reported reassurance that no serious condition is causing their pain and continuing with daily activities is safe. Secondary outcomes measured management intentions, credibility and relevance of the education, and similarity to previous education. Two thousand two hundred thirty-seven participants were randomised and provided primary outcome data. Best practice education increased reassurance that no serious condition is causing their pain (estimated mean effect 0.5 on a 0-10 scale, 95% confidence interval [CI] 0.2-0.7) and continuing with daily activities is safe (0.6, 95% CI 0.3-0.8) compared with structure-focused education . Adding pain science messages to best practice education slightly increased both measures of reassurance (0.2, 95% CI 0.0-0.4). Clinicians treating patients with rotator cuff-related shoulder pain should highlight that most shoulder pain is not serious or a good indicator of tissue damage and recommend simple self-management strategies. The benefit of adding pain science messages is small. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35220 Patients', physiotherapists' and other stakeholders' experiences and perceptions about supported home physiotherapy for people with musculoskeletal conditions: a qualitative study Withers, H.G.; Liu, H.; Glinsky, J.V.; Chu, J.; Jennings, M.D.; Hayes, A.J.; Starkey, I.; Palmer, B.A.; Szymanek, L.; Cruwys, J.J.; Wong, D.; Duong, K.; Barnett, A.; Tindall, M.; Lucas, B.; Lambert, T.E.; Taylor, D.; Sherrington, C.; Ferreira, M.; Maher, C.; Zadro, J.; Hart, K.; Hodge, W.; Harvey, L.A. OBJECTIVES: Exercise, support and advice are the key treatment strategies of musculoskeletal problems. The aims of this study were to determine patients', physiotherapists', and other stakeholders' perspectives about supported home physiotherapy for the management of musculoskeletal problems and to identify the barriers and facilitators to rolling out this model of physiotherapy service delivery. METHODS: This study was conducted as part of a process evaluation run alongside a large trial designed to determine whether supported home physiotherapy is as good or better than a course of in-person physiotherapy. Forty interviews were conducted with 20 trial participants, 15 physiotherapists, and 5 other stakeholders. The interviews were semi-structured and based on interview guides. Each interview was transcribed and a three-tiered coding tree was developed. RESULTS: Six key themes were identified. Supported home physiotherapy (i) is convenient for some patients, (ii) does not always align with patients' and therapists' expectations about treatment (iii) is suitable for some but not all, (iv) can reduce personal connection and accountability, (v) has implications for physiotherapists' workloads, and (vi) has barriers and facilitators to future implementation. CONCLUSIONS: Findings suggest that patients are far more accepting of supported home physiotherapy than physiotherapists assume. This model of service delivery could be rolled out to improve access to physiotherapy and to provide a convenient and effective way of delivering physiotherapy to some patients with musculoskeletal conditions if our trial results indicate that supported home physiotherapy is as good or better than in-person physiotherapy. CLINICAL TRIAL REGISTRY NUMBER: ACTRN12619000065190 CONTRIBUTIONS OF THIS PAPER. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35222 Clinimetrics: Keele STarT MSK tool Zadro, J.R. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35219 Remotely delivered physiotherapy is as effective as face-to-face physiotherapy for musculoskeletal conditions (REFORM): a randomised trial Withers, H.G.; Glinsky, J.V.; Chu, J.; Jennings, M.D.; Starkey, I.; Parmeter, R.; Boulos, M.; Cruwys, J.J.; Duong, K.; Jordan, I.; Wong, D.; Trang, S.; Duong, M.; Liu, H.; Hayes, A.J.; Lambert, T.E.; Zadro, J.R.; Sherrington, C.; Maher, C.; Lucas, B.R.; Taylor, D.; Ferreira, M.L.; Harvey, L.A. QUESTION: Is remotely delivered physiotherapy as good or better than face-to-face physiotherapy for the management of musculoskeletal conditions? DESIGN: Randomised controlled, non-inferiority trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: A total of 210 adult participants with a musculoskeletal condition who presented for outpatient physiotherapy at five public hospitals in Sydney. INTERVENTION: One group received a remotely delivered physiotherapy program for 6 weeks that consisted of one face-to-face physiotherapy session in conjunction with weekly text messages, phone calls at 2 and 4 weeks, and an individualised home exercise program delivered through an app. The other group received usual face-to-face physiotherapy care in an outpatient setting. OUTCOME MEASURES: The primary outcome was the Patient Specific Functional Scale at 6 weeks with a pre-specified non-inferiority margin of -15 out of 100 points. Secondary outcomes included: the Patient Specific Functional Scale at 26 weeks; kinesiophobia, pain, function/disability, global impression of change and quality of life at 6 and 26 weeks; and satisfaction with service delivery at 6 weeks. RESULTS: The mean between-group difference (95% CI) for the Patient Specific Functional Scale at 6 weeks was 2.7 out of 100 points (-3.5 to 8.8), where a positive score favoured remotely delivered physiotherapy. The lower end of the 95% CI was greater than the non-inferiority margin. Whilst non-inferiority margins were not set for the secondary outcomes, the 95% CI of the mean between-group difference ruled out clinically meaningful differences. CONCLUSION: Remotely delivered physiotherapy with support via phone, text and an app is as good as face-to-face physiotherapy for the management of musculoskeletal conditions. TRIAL REGISTRATION: ACTRN12619000065190. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35218 RECITAL: a non-inferiority randomised control trial evaluating a virtual fracture clinic compared with in-person care for people with simple fractures (study protocol) Teng, M.J.; Zadro, J.R.; Pickles, K.; Copp, T.; Shaw, M.J.; Khoudair, I.; Horsley, M.; Warnock, B.; Hutchings, O.R.; Petchell, J.F.; Ackerman, I.N.; Drayton, A.; Liu, R.; Maher, C.G.; Traeger, A.C. INTRODUCTION: Most simple undisplaced fractures can be managed without surgery by immobilising the limb with a splint, prescribing medication for pain, and providing advice and early rehabilitation. Recent systematic reviews based on retrospective observational studies have reported that virtual fracture clinics can deliver follow-up care that is safe and cost-effective. However, no randomised controlled trial has investigated if a virtual fracture clinic can provide non-inferior physical function outcomes compared with an in-person clinic for patients with simple fractures. METHODS AND ANALYSIS: 312 participants will be recruited from 2 metropolitan hospitals located in Sydney, Australia. Adult patients will be eligible if they have an acute simple fracture that can be managed with a removable splint and is deemed appropriate for follow-up at either the virtual or in-person fracture clinic by an orthopaedic doctor. Patients will not be eligible if they have a complex fracture that requires a cast or surgery. Eligible participants will be randomised to receive their follow-up care either at the virtual or the in-person fracture clinic. Participants at the virtual fracture clinic will be reviewed within 5?days of receiving a referral through video calls with a physiotherapist. Participants at the in-person fracture clinic will be reviewed by an orthopaedic doctor within 7-10 days of receiving a referral. The primary outcome will be the patient's function measured using the Patient-Specific Functional Scale at 12 weeks. Secondary outcomes will include health-related quality of life, patient-reported experiences, pain, health cost, healthcare utilisation, medication use, adverse events, emergency department representations and surgery. ETHICS AND DISSEMINATION: The study has been approved by the Sydney Local Health District Ethics Review Committee (RPAH Zone) (X23-0200 and 2023/ETH01038). The trial results will be submitted for publication in a reputable international journal and will be presented at professional conferences. TRIAL REGISTRATION NUMBER: ACTRN12623000934640. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35217 Social Media Promotion of Health Tests With Potential for Overdiagnosis or Overuse: Protocol for a Content Analysis Nickel, B.; Heiss, R.; Shih, P.; Gram, E.G.; Copp, T.; Taba, M.; Moynihan, R.; Zadro, J. BACKGROUND: In recent years, social media have emerged as important spaces for commercial marketing of health tests, which can be used for the screening and diagnosis of otherwise generally healthy people. However, little is known about how health tests are promoted on social media, whether the information provided is accurate and balanced, and if there is transparency around conflicts of interest. OBJECTIVE: This study aims to understand and quantify how social media is being used to discuss or promote health tests with the potential for overdiagnosis or overuse to generally healthy people. METHODS: Content analysis of social media posts on the anti-Mullerian hormone test, whole-body magnetic resonance imaging scan, multicancer early detection, testosterone test, and gut microbe test from influential international social media accounts on Instagram and TikTok. The 5 tests have been identified as having the following criteria: (1) there are evidence-based concerns about overdiagnosis or overuse, (2) there is evidence or concerns that the results of tests do not lead to improved health outcomes for generally healthy people and may cause harm or waste, and (3) the tests are being promoted on social media to generally healthy people. English language text-only posts, images, infographics, articles, recorded videos including reels, and audio-only posts are included. Posts from accounts with <1000 followers as well as stories, live videos, and non-English posts are excluded. Using keywords related to the test, the top posts were searched and screened until there were 100 eligible posts from each platform for each test (total of 1000 posts). Data from the caption, video, and on-screen text are being summarized and extracted into a Microsoft Excel (Microsoft Corporation) spreadsheet and included in the analysis. The analysis will take a combined inductive approach when generating key themes and a deductive approach using a prespecified framework. Quantitative data will be analyzed in Stata SE (version 18.0; Stata Corp). RESULTS: Data on Instagram and TikTok have been searched and screened. Analysis has now commenced. The findings will be disseminated via publications in peer-reviewed international medical journals and will also be presented at national and international conferences in late 2024 and 2025. CONCLUSIONS: This study will contribute to the limited evidence base on the nature of the relationship between social media and the problems of overdiagnosis and overuse of health care services. This understanding is essential to develop strategies to mitigate potential harm and plan solutions, with the aim of helping to protect members of the public from being marketed low-value tests, becoming patients unnecessarily, and taking resources away from genuine needs within the health system. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/56899. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35216 Process and implementation evaluation of a virtual hospital model of care for low back pain (Back@Home) Melman, A.; Teng, M.J.; Coombs, D.M.; Li, Q.; Billot, L.; Lung, T.; Rogan, E.; Marabani, M.; Hutchings, O.; Zadro, J.R.; Maher, C.G.; Machado, G.C. OBJECTIVES: Low back pain was the sixth most common reason for an ED visit in 2022-2023 in Australia, one-third of these patients were subsequently admitted to hospital. Therefore, we have assessed whether some patients could be diverted to alternate clinical pathways, via admission to a virtual hospital (rpavirtual), and be cared for remotely in their own homes. METHODS: Ethics approval was granted for protocols X21-0278 & 2021/ETH10967 and X21-0094 & 2021/ETH00591. We conducted a mixed-method process evaluation, using the RE-AIM framework (reach, effectiveness, adoption, implementation and maintenance) to answer key questions regarding the Back@Home model of care. RESULTS: This preliminary evaluation describes a cohort of the first 50 patients who received care between 13 February and 31 July 2023. The service had high levels of reach and adoption, very low levels of ED representation, and no AEs. Virtual care cost a median of AU$2215 (interquartile range = AU$1724-AU$2855) per admission. Patients admitted virtually had the same high satisfaction with care as traditionally admitted patients and reported less pain and better physical function. CONCLUSIONS: Preliminary findings suggest that this model of care is a safe, acceptable, and feasible alternative to hospitalisation for non-serious low back pain, in a select cohort of patients meeting inclusion criteria. Further data collection will inform whether Back@Home has had an impact on length of stay or traditional admission rates. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35215 People With Acute Low Back Pain Have Concerns That May Not Be Addressed by Guideline-Recommended Advice: A Mixed-Methods Study Lam, S.A.; Zadro, J.R.; Maher, C.G.; Juan, C.S.; Wang, H.; Ferreira, G.E. OBJECTIVE: To investigate what concerns people with acute low back pain (LBP) and explore whether demographic and clinical factors were associated with having concerns about LBP. DESIGN: Mixed-methods study. METHODS: We included participants aged ?18 years with acute LBP (LBP?6 weeks). We collected demographic and clinical characteristics via an online survey and asked one open-ended question to elicit participants' concerns about their LBP. We investigated concerns about LBP using inductive content analysis. Using multivariable logistic regression, we explored associations between demographic and clinical characteristics and having concerns about LBP. RESULTS: We included 2025 participants, a majority of whom (n = 1200, 59.3%) reported having at least 1 concern about their LBP. There were 34 unique concerns, which mapped to 5 themes: causes of LBP (n = 393, 19.4%), future consequences of LBP (n = 390, 19.3%), psychosocial consequences of LBP (n = 287, 14.2%), physical consequences of LBP (n = 210, 10.4%), and health consequences of LBP (n = 84, 4.2%). Demographic and clinical characteristics were associated with having concerns about LBP: participants with university education, having previously received advice for LBP, with higher LBP intensity, interference, and higher anxiety symptoms were more likely to have concerns about their LBP. CONCLUSION: Most people with acute LBP had at least 1 concern about their LBP, more commonly centered around the causes of and the future consequences of LBP. J Orthop Sports Phys Ther 2024;54(9):1-9. Epub 7 August 2024. doi:10.2519/jospt.2024.12571. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35211 Prioritisation of clinical trial learning needs of musculoskeletal researchers: an inter-disciplinary modified Delphi study by the Australia & New Zealand musculoskeletal clinical trials network Filbay, S.R.; Ferreira, G.E.; Metcalf, B.; Buchbinder, R.; Ramsay, H.; Abbott, J.H.; Darlow, B.; Zadro, J.R.; Davidson, S.R.E.; Searle, E.; McKenzie, B.J.; Hinman, R.S. BACKGROUND: There is a need to increase the capacity and capability of musculoskeletal researchers to design, conduct, and report high-quality clinical trials. The objective of this study was to identify and prioritise clinical trial learning needs of musculoskeletal researchers in Australia and Aotearoa New Zealand. Findings will be used to inform development of an e-learning musculoskeletal clinical trials course. METHODS: A two-round online modified Delphi study was conducted with an inter-disciplinary panel of musculoskeletal researchers from Australia and Aotearoa New Zealand, representing various career stages and roles, including clinician researchers and consumers with lived experience of musculoskeletal conditions. Round 1 involved panellists nominating 3-10 topics about musculoskeletal trial design and conduct that they believe would be important to include in an e-learning course about musculoskeletal clinical trials. Topics were synthesised and refined. Round 2 asked panellists to rate the importance of all topics (very important, important, not important), as well as select and rank their top 10 most important topics. A rank score was calculated whereby higher scores reflect higher rankings by panellists. RESULTS: Round 1 was completed by 121 panellists and generated 555 individual topics describing their musculoskeletal trial learning needs. These statements were grouped into 37 unique topics for Round 2, which was completed by 104 panellists. The topics ranked as most important were: (1) defining a meaningful research question (rank score 560, 74% of panellists rated topic as very important); (2) choosing the most appropriate trial design (rank score 410, 73% rated as very important); (3) involving consumers in trial design through to dissemination (rank score 302, 62% rated as very important); (4) bias in musculoskeletal trials and how to minimise it (rank score 299, 70% rated as very important); and (5) choosing the most appropriate control/comparator group (rank score 265, 65% rated as very important). CONCLUSIONS: This modified Delphi study generated a ranked list of clinical trial learning needs of musculoskeletal researchers. Findings can inform training courses and professional development to improve researcher capabilities and enhance the quality and conduct of musculoskeletal clinical trials. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35214 Effectiveness of implementation strategies for increasing clinicians' use of five validated imaging decision rules for musculoskeletal injuries: a systematic review Kharel, P.; Zadro, J.R.; Wong, G.; Rojanabenjawong, K.; Traeger, A.; Linklater, J.; Maher, C.G. BACKGROUND: Strategies to enhance clinicians' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear. OBJECTIVE: To evaluate the effectiveness of various implementation strategies for increasing clinicians' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule). DESIGN: Systematic review. METHODS: The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules. RESULTS: We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians' long-term knowledge of the Ottawa Ankle Rules. CONCLUSION: Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35213 The brief pain inventory-Interference Subscale has acceptable reliability but questionable validity in acute back and neck pain populations Jones, C.M.P.; Lin, C.C.; Zadro, J.; Verhagen, A.; Hancock, M.; Ostelo, R. BACKGROUND: The Brief Pain Inventory-Interference Subscale (BPI-IS) is a subscale of the BPI assessment tool developed to rapidly assess the impact of a person's pain on their function. It is uncertain whether it has one or two factors, and whether it has acceptable clinimetric properties in a mixed spinal pain (back and/or neck) population. OBJECTIVES: To determine the clinimetric properties of the BPI-IS in a population with mixed spinal pain. METHODS: We completed a clinimetric evaluation with a test-retest design, factor analysis, and hypothesis testing. We used data collected for a randomised clinical trial including a population presenting to primary care or emergency departments with acute spinal pain (back and/or neck). RESULTS: Confirmatory factor analysis better supported the two-factor model of the BPI-IS (physical interference factor and affective interference factor) as compared to the one-factor model. Both one and two-factor models had acceptable reliability (high internal consistency and no evidence of floor or ceiling effects). Both models failed to reach our a-priori thresholds for acceptable construct (cross sectional) validity, and responsiveness (longitudinal validity) in either back or neck pain populations. CONCLUSION: The BPI-IS has two factors and both have acceptable reliability, but tests for validity did not reach our a priori thresholds for acceptability (construct validity and responsiveness). The BPI-IS may not be suitable to measure the impact of pain on function in back and neck pain populations. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35212 Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study Gamble, A.R.; McKay, M.J.; Anderson, D.B.; Pappas, E.; Cooper, I.A.; Macpherson, S.; Harris, I.A.; Filbay, S.R.; McCaffery, K.; Thompson, R.; Hoffmann, T.C.; Maher, C.G.; Zadro, J.R. AIM: To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction. DESIGN: Mixed-methods study describing the development of a patient decision aid. SETTING: A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids. PARTICIPANTS: People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group. PRIMARY AND SECONDARY OUTCOMES: Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis. RESULTS: We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms. CONCLUSION: Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35208 Perceptions of advice for acute low back pain: a content analysis of qualitative data collected in a randomised experiment Augustine, L.; Zadro, J.; Maher, C.; Traeger, A.C.; Jones, C.; West, C.A.; Yang, J.; O'Keeffe, M.; Jenkins, H.; McAuley, J.H.; Ferreira, G.E. OBJECTIVES: To explore how people perceive three different forms of advice for acute low back pain (LBP). DESIGN: Content analysis of qualitative data collected in a three-arm randomised experiment. PARTICIPANTS: 2200 participants with acute LBP (ie, pain duration for ?6 weeks) were randomly assigned to receive three types of advice: guideline advice and guideline advice with the addition of either brief pain science or ergonomics messages. PRIMARY AND SECONDARY OUTCOMES: After receiving the advice, participants answered two questions: 'If your health professional gave you this advice, how would it make you feel?' and 'If your health professional gave you this advice, what treatments (if any) do you think you would need?' Two researchers coded responses using deductive content analysis. RESULTS: We analysed 4400 free-text responses from 2200 participants. There were little to no differences in participants' feelings, thoughts and expectations after receiving three types of advice for acute LBP. Participants most commonly expressed feeling positive about the advice (38%-35%), reassured (23%-22%) and empowered (10%-8%). Some expressed being unhappy or being frustrated with the advice (4%-3%). Participants most commonly thought they needed no treatment apart from staying active, followed by exercise and medication. CONCLUSIONS: Guideline advice with or without the addition of brief pain science or ergonomics messages generated positive feelings, reassurance or a sense of empowerment in many people with acute LBP, with no difference between types of advice. TRIAL REGISTRATION NUMBER: ACTRN12623000364673. 2024-01-01T00:00:00Z https://hdl.handle.net/2123/35207 How do people perceive different advice for rotator cuff disease? A content analysis of qualitative data collected in a randomised experiment Zadro, J.R.; Michaleff, Z.A.; O'Keeffe, M.; Ferreira, G.E.; Traeger, A.C.; Gamble, A.R.; Afeaki, F.; Li, Y.; Wen, E.; Yao, J.; Zhu, K.; Page, R.; Harris, I.A.; Maher, C.G. OBJECTIVES: To explore how people perceive different advice for rotator cuff disease in terms of words/feelings evoked by the advice and treatment needs. SETTING: We performed a content analysis of qualitative data collected in a randomised experiment. PARTICIPANTS: 2028 people with shoulder pain read a vignette describing someone with rotator cuff disease and were randomised to: bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation emphasised that treatment is needed for recovery. PRIMARY AND SECONDARY OUTCOMES: Participants answered questions about: (1) words/feelings evoked by the advice; (2) treatments they feel are needed. Two researchers developed coding frameworks to analyse responses. RESULTS: 1981 (97% of 2039 randomised) responses for each question were analysed. Guideline-based advice (vs treatment recommendation) more often elicited words/feelings of reassurance, having a minor issue, trust in expertise and feeling dismissed, and treatment needs of rest, activity modification, medication, wait and see, exercise and normal movements. Treatment recommendation (vs guideline-based advice) more often elicited words/feelings of needing treatment/investigation, psychological distress and having a serious issue, and treatment needs of injections, surgery, investigations, and to see a doctor. CONCLUSIONS: Words/feelings evoked by advice for rotator cuff disease and perceived treatment needs may explain why guideline-based advice reduces perceived need for unnecessary care compared to a treatment recommendation. 2023-01-01T00:00:00Z https://hdl.handle.net/2123/35210 Work-Related Musculoskeletal Disorders in Endoscopic Sinus and Skull Base Surgery: A Systematic Review With Meta-analysis Campbell, R.G.; Zadro, J.R.; Gamble, A.R.; Chan, C.L.; Mackey, M.G.; Osie, G.; Png, L.H.; Douglas, R.G.; Pappas, E. OBJECTIVE: Endoscopic sinus and skull base surgery has led to significant improvements in patient outcomes, yet may have come at a cost to surgeons' musculoskeletal (MSK) health. We aimed to determine the prevalence and characteristics of work-related MSK disorders (WRMDs) in endoscopic sinus and skull base surgeons; to investigate contributing factors for WRMD in this population; and to evaluate the effectiveness of ergonomic interventions on the severity or prevalence of WRMD in this population. DATA SOURCES: Medline, Embase, CINAHL, Web of Science, and Scopus from inception to April 2, 2024. A bibliographic examination was performed for further papers. REVIEW METHODS: Inclusion criteria included original peer-reviewed papers with work-related MSK outcomes (prevalence, contributing factors, and interventions) relating to endoscopic sinus and/or skull base surgeons in any language. RESULTS: Of 25,772 unique citations, 37 studies met the inclusion criteria. The pooled lifetime, point, and 12-month prevalences of WRMD were 75.9% (95% confidence interval; I(2), 67.2%-83.6%, I(2) 95.6%), 80.8% (77.0%-84.3%, I(2) 98.0%), and 82.0% (71.8%-90.3%, I(2) 60.96%) respectively. The neck, lumbar spine, and thoracic spine were the most commonly involved areas. One of 9 studies on contributing factors investigated discomfort as an outcome. The remainder focussed on surrogate outcomes (eg, posture, hand dysfunction). Two of the 13 intervention studies investigated pain or fatigue as an outcome. The remainder targeted posture, muscle activity, or workload. CONCLUSION: WRMDs are highly prevalent in endoscopic sinus and skull base surgeons. Further studies focusing on the direct outcomes of WRMD such as pain are needed. 2024-01-01T00:00:00Z