Publications by authors named "Gustavo C Machado"

44 Publications

Virtual hospitals: why we need them, how they work and what might come next.

J Physiother 2021 Jun 17. Epub 2021 Jun 17.

Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Sydney, Australia.

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http://dx.doi.org/10.1016/j.jphys.2021.06.018DOI Listing
June 2021

Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial.

BMJ Qual Saf 2021 Mar 10. Epub 2021 Mar 10.

Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.

Background: Overuse of lumbar imaging is common in the emergency department (ED). Few trials have examined interventions to address this. We evaluated the effectiveness of a multifaceted intervention to implement guideline recommendations for low back pain in the emergency department.

Methods: We conducted a stepped-wedge, cluster-randomised trial in four EDs in New South Wales, Australia. After a 13-month control phase of usual care, the EDs received a multifaceted intervention to support guideline-endorsed care in a random order, based on a computer-generated random sequence, every 4 weeks over a 4-month period. All sites were followed up for at least 3 months. The primary outcome was the proportion of low back pain presentations receiving lumbar imaging. Secondary healthcare utilisation outcomes included prescriptions of opioid and non-opioid pain medicines, inpatient admissions, length of ED stay, specialist referrals and re-presentations. Clinician beliefs and knowledge about low back pain care were measured before and after the intervention. Patient-reported pain, disability, quality of life and satisfaction were measured at 1, 2 and 4 weeks post ED presentation.

Results: A total of 269 ED clinicians and 4625 episodes of care for low back pain (4491 patients) were included. The data did not provide clear evidence that the intervention reduced lumbar imaging (OR 0.77; 95% CI 0.47 to 1.26; p=0.29). It did reduce opioid use (OR 0.57; 95% CI 0.38 to 0.85; p=0.006) and improved clinicians' beliefs (mean difference (MD), 2.85; 95% CI 1.85 to 3.85; p<0.001; on a scale from 9 to 45) and knowledge about low back pain care (MD, 0.48; 95% CI 0.13 to 0.83; p<0.01; on a scale from 0 to 11). There was no difference in pain scores at 1-week follow-up (MD, 0.04; 95% CI -1.00 to 1.08; p=0.94; on a scale from 0 to 10). A similar trend was observed for all other patient-reported outcomes and time points. This study found no effect on the other secondary healthcare utilisation outcomes.

Conclusion: It is uncertain if a multifaceted intervention to implement guideline recommendations for low back pain care decreased lumbar imaging in the ED; however, it did reduce opioid prescriptions without adversely affecting patient outcomes. ACTRN12617001160325.
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http://dx.doi.org/10.1136/bmjqs-2020-012337DOI Listing
March 2021

Text Messaging and Web-Based Survey System to Recruit Patients With Low Back Pain and Collect Outcomes in the Emergency Department: Observational Study.

JMIR Mhealth Uhealth 2021 03 4;9(3):e22732. Epub 2021 Mar 4.

Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.

Background: Low back pain (LBP) is a frequent reason for emergency department (ED) presentations, with a global prevalence of 4.4%. Despite being common, the number of clinical trials investigating LBP in the ED is low. Recruitment of patients in EDs can be challenging because of the fast-paced and demanding ED environment.

Objective: The aim of this study is to describe the recruitment and response rates using an SMS text messaging and web-based survey system supplemented by telephone calls to recruit patients with LBP and collect health outcomes in the ED.

Methods: An automated SMS text messaging system was integrated into Research Electronic Data Capture and used to collect patient-reported outcomes for an implementation trial in Sydney, Australia. We invited patients with nonserious LBP who presented to participating EDs at 1, 2, and 4 weeks after ED discharge. Patients who did not respond to the initial SMS text message invitation were sent a reminder SMS text message or contacted via telephone. The recruitment rate was measured as the proportion of patients who agreed to participate, and the response rate was measured as the proportion of participants completing the follow-up surveys at weeks 2 and 4. Regression analyses were used to explore factors associated with response rates.

Results: In total, 807 patients with nonserious LBP were invited to participate and 425 (53.0%) agreed to participate. The week 1 survey was completed by 51.5% (416/807) of participants. At week 2, the response rate was 86.5% (360/416), and at week 4, it was 84.4% (351/416). Overall, 60% of the surveys were completed via SMS text messaging and on the web and 40% were completed via telephone. Younger participants and those from less socioeconomically disadvantaged areas were more likely to respond to the survey via the SMS text messaging and web-based system.

Conclusions: Using an SMS text messaging and web-based survey system supplemented by telephone calls is a viable method for recruiting patients with LBP and collecting health outcomes in the ED. This hybrid system could potentially reduce the costs of using traditional recruitment and data collection methods (eg, face-to-face, telephone calls only).

International Registered Report Identifier (irrid): RR2-10.1136/bmjopen-2017-019052.
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http://dx.doi.org/10.2196/22732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7974753PMC
March 2021

Low back pain presentations to New South Wales emergency departments: Trends over time and geographical variation.

Emerg Med Australas 2021 Feb 22. Epub 2021 Feb 22.

Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.

Objective: To determine whether rates of ED presentations because of low back pain (LBP) have increased from 2016 to 2019 in New South Wales and map the geographical distribution of ED presentations because of LBP across New South Wales.

Methods: We sourced data from the New South Wales Emergency Department Records for Epidemiology. We included all ED presentations aged 15 years and older with a diagnosis of LBP to the 178 public EDs across New South Wales from 1 January 2016 to 31 December 2019. We calculated the ratio (95% confidence interval) between the 2016 and 2019 age-standardised rates to determine whether an increase in the rate of ED LBP presentations has occurred. To assess geographical variation, we aggregated presentations by their home postcode. We calculated age-standardised rates per 100 000 person year for each of those areas using data from 2016 to 2019.

Results: We included 188 275 LBP presentations for patients aged 15 years or older. Their mean (standard deviation) age was 51.3 (20.0) years. From 2016 to 2019, we observed a 5.3% increase in the age-adjusted LBP ED presentation rates (age-standardised ratio 1.05, 95% confidence interval 1.04-1.06). We found a 20-fold variation in LBP ED age-standardised presentation rates across the different local government areas of New South Wales. Higher rates were mostly observed in rural and regional areas.

Conclusions: The demand for ED services because of LBP has increased in New South Wales over time, and we observed a 20-fold variation in presentation rates across different regions.
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http://dx.doi.org/10.1111/1742-6723.13745DOI Listing
February 2021

Non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain.

BMJ 2021 01 29;372:n104. Epub 2021 Jan 29.

Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.

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http://dx.doi.org/10.1136/bmj.n104DOI Listing
January 2021

Drugs for chronic pain.

Br J Gen Pract 2020 12 26;70(701):576-577. Epub 2020 Nov 26.

Warwick Clinical Trials Unit, University of Warwick; University Hospitals Coventry and Warwickshire, Coventry, UK.

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http://dx.doi.org/10.3399/bjgp20X713549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7707052PMC
December 2020

Validation of the Mobile Application Rating Scale (MARS).

PLoS One 2020 2;15(11):e0241480. Epub 2020 Nov 2.

Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University Ulm, Ulm, Germany.

Background: Mobile health apps (MHA) have the potential to improve health care. The commercial MHA market is rapidly growing, but the content and quality of available MHA are unknown. Instruments for the assessment of the quality and content of MHA are highly needed. The Mobile Application Rating Scale (MARS) is one of the most widely used tools to evaluate the quality of MHA. Only few validation studies investigated its metric quality. No study has evaluated the construct validity and concurrent validity.

Objective: This study evaluates the construct validity, concurrent validity, reliability, and objectivity, of the MARS.

Methods: Data was pooled from 15 international app quality reviews to evaluate the metric properties of the MARS. The MARS measures app quality across four dimensions: engagement, functionality, aesthetics and information quality. Construct validity was evaluated by assessing related competing confirmatory models by confirmatory factor analysis (CFA). Non-centrality (RMSEA), incremental (CFI, TLI) and residual (SRMR) fit indices were used to evaluate the goodness of fit. As a measure of concurrent validity, the correlations to another quality assessment tool (ENLIGHT) were investigated. Reliability was determined using Omega. Objectivity was assessed by intra-class correlation.

Results: In total, MARS ratings from 1,299 MHA covering 15 different health domains were included. Confirmatory factor analysis confirmed a bifactor model with a general factor and a factor for each dimension (RMSEA = 0.074, TLI = 0.922, CFI = 0.940, SRMR = 0.059). Reliability was good to excellent (Omega 0.79 to 0.93). Objectivity was high (ICC = 0.82). MARS correlated with ENLIGHT (ps<.05).

Conclusion: The metric evaluation of the MARS demonstrated its suitability for the quality assessment. As such, the MARS could be used to make the quality of MHA transparent to health care stakeholders and patients. Future studies could extend the present findings by investigating the re-test reliability and predictive validity of the MARS.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241480PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605637PMC
December 2020

Emergency department interventions for adult patients with low back pain: a systematic review of randomised controlled trials.

Emerg Med J 2021 Jan 9;38(1):59-68. Epub 2020 Oct 9.

Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.

Background: Most low back pain trials have limited applicability to the emergency department (ED) because they provide treatment and measure outcomes after discharge from the ED. We investigated the efficacy and safety of pharmacological and non-pharmacological interventions delivered in the ED to patients with non-specific low back pain and/or sciatica on patient-relevant outcomes measured during the emergency visit.

Methods: Literature searches were performed in MEDLINE, EMBASE and CINAHL from inception to week 1 February 2020. We included all randomised controlled trials investigating adult patients (≥18 years) with non-specific low back pain and/or sciatica presenting to ED. The primary outcome of interest was pain intensity. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias of each trial using the Physiotherapy Evidence Database (PEDro) scale. The overall quality of evidence, or certainty, provided by a set of trials evaluating the same treatment was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers imprecision, inconsistency, indirectness and bias in the evidence.

Results: Fifteen trials (1802 participants) were included with 12 of 15 at low risk of bias (ie, PEDro score >6). Based on results from individual trials and moderate quality evidence, ketoprofen gel was more effective than placebo for non-specific low back pain at 30 min (mean difference (MD) -15.0, 95% confidence interval (CI) -21.0 to -9.0). For those with sciatica (moderate quality evidence), intravenous paracetamol (acetaminophen) (MD -15.7, 95% CI -19.8 to -11.6) and intravenous morphine (MD -11.4, 95% CI -21.6 to -1.2) were both superior to placebo at 30 min. Based on moderate quality of evidence, corticosteroids showed no benefits against placebo at emergency discharge for non-specific low back pain (MD 9.0, 95% CI -0.71 to 18.7) or sciatica (MD -6.8, 95% CI -24.2 to 10.6). There were conflicting results from trials comparing different pharmacological options (moderate quality evidence) or investigating non-pharmacological treatments (low quality evidence).

Conclusion: Ketoprofen gel for non-specific low back pain and intravenous paracetamol or morphine for sciatica were superior to placebo, whereas corticosteroids were ineffective for both conditions. There was conflicting evidence for comparisons of different pharmacological options and those involving non-pharmacological treatments. Additional trials measuring important patient-related outcomes to EDs are needed.
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http://dx.doi.org/10.1136/emermed-2020-209588DOI Listing
January 2021

Clinical course of patients with low back pain following an emergency department presentation: a systematic review and meta-analysis.

Emerg Med J 2020 Sep 11. Epub 2020 Sep 11.

Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.

Introduction: Low back pain, and especially non-specific low back pain, is a common cause of presentation to the emergency department (ED). Although these patients typically report relatively high pain intensity, the clinical course of their pain and disability remains unclear. Our objective was to review the literature and describe the clinical course of non-specific low back pain after an ED visit.

Methods: Electronic searches were conducted using MEDLINE, CINAHL and EMBASE from inception to March 2019. We screened for cohort studies or randomised trials investigating pain or disability in patients with non-specific low back pain presenting to EDs. We excluded studies that enrolled participants with minimal pain or disability scores at baseline. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias and quality of evidence. Estimates of pain and disability were converted to a common 0-100 scale. We estimated pooled means and 95% CIs of pain and disability as a function of time since ED presentation.

Results: Eight studies (nine publications) with a total of 1994 patients provided moderate overall quality evidence of the expected clinical course of low back pain after an ED visit. Seven of the eight studies were assessed to have a low risk of bias. At the time of the ED presentation, the pooled estimate of the mean pain score on a 0-100 scale was 71.0 (95% CI 64.2-77.9). This reduced to 46.1 (95% CI 37.2-55.0) after 1 day, 41.8 (95% CI 34.7 to 49.0) after 1 week and 13.5 (95% CI 5.8-21.3) after 26 weeks. The course of disability followed a similar pattern.

Conclusions: Patients presenting to EDs with non-specific low back pain experience rapid reductions in pain intensity, but on average symptoms persisted 6 months later. This review can be used to educate patients so they can have realistic expectations of their recovery.
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http://dx.doi.org/10.1136/emermed-2019-209294DOI Listing
September 2020

Clinimetrics: Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

J Physiother 2021 Jan 25;67(1):66. Epub 2020 Aug 25.

Institute for Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia. Electronic address:

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http://dx.doi.org/10.1016/j.jphys.2020.07.003DOI Listing
January 2021

Emergency department care for low back pain: Should we adopt recommendations from primary care guidelines?

Emerg Med Australas 2020 10 2;32(5):890-892. Epub 2020 Aug 2.

Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.

ED visits for low back pain are increasing, but the lack of specific guidance for emergency physicians impedes evidence-based care, and adopting primary care recommendations may not be appropriate. The ED sees a different spectrum of low back pain presentations, where physicians are likely to encounter a larger proportion of patients with an underlying serious pathology or non-spinal diseases than in primary care. Current low back pain guidelines do not adequately cover screening for these conditions, but making a differential diagnosis is crucial in emergency patients with low back pain. In this article, we also discuss the challenges in developing specific ED guidelines for low back pain, the limited evidence on the profile of these patients and the surprising dearth of randomised trials.
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http://dx.doi.org/10.1111/1742-6723.13593DOI Listing
October 2020

Why a dearth of sports and exercise medicine/physiotherapy research using hospital electronic medical records? A success story and template for researchers.

Br J Sports Med 2020 May 21. Epub 2020 May 21.

Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1136/bjsports-2019-101622DOI Listing
May 2020

Enthusiastic claims for open-label placebo pills ignore the evidence.

Pain 2020 05;161(5):1124

The University of Sydney, Sydney School of Public Health, Faculty of Medicine and Health, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1097/j.pain.0000000000001803DOI Listing
May 2020

What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments.

Pain 2020 04;161(4):694-702

Faculty of Medicine, Memorial University of Newfoundland, Canada.

International clinical practice guidelines for low back pain (LBP) contain consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids. This systematic review describes usual care provided by first-contact physicians to patients with LBP. Studies that reported the assessments and care provided to people with LBP in family practice and emergency departments (EDs) from January 2000 to May 2019 were identified by searches of PubMed, EMBASE, and CINAHL. Study quality was assessed with reference to representativeness of samples, potential misclassification of patients, potential misclassification of outcomes, inconsistent data and precision of the estimate, and the findings of high-quality studies were prioritized in the data synthesis. We included 26 studies that reported data from almost 195,000 patients: 18 from family practice, and 8 from EDs. Less than 20% of patients with LBP received evidence-based information and advice from their family practitioner. Around 1 in 4 patients with LBP received referral for imaging in family practice and 1 in 3 in EDs. Up to 30% of patients with LBP were prescribed opioids in family practice and up to 60% in EDs. Large numbers of patients who saw a physician for LBP received care that is inconsistent with evidence-based clinical practice guidelines. Usual care included overuse of imaging and opioid prescription and underuse of advice and information. Suboptimal care may contribute to the massive burden of the condition worldwide.
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http://dx.doi.org/10.1097/j.pain.0000000000001751DOI Listing
April 2020

Barriers to participation in a placebo-surgical trial for lumbar spinal stenosis.

Heliyon 2019 May 20;5(5):e01683. Epub 2019 May 20.

Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, Australia.

Background: Placebo-controlled trials are an important tool when assessing the efficacy of spinal surgical procedures. The most common spinal surgical procedure in older adults is decompression for lumbar spinal stenosis. Before conducting a placebo-surgical trial on decompression surgery, an investigation of patients' willingness to participate in a placebo-controlled trial of decompression surgery and barriers to participation were explored.

Materials: An online survey.

Methods: Descriptive analyses of demographic and clinical data, and participants' willingness to participate in a placebo-surgical trial. Logistic regression was used to examine potential predictors of willingness to participate. Two independent researchers performed a coded framework analysis of patients' barriers to participation.

Results: 68 patients were invited and 63 participants completed the survey (91.3% response, mean (SD) age 69.5 (10.9) years, 52% females), 71% suffered from moderate to very severe pain. Ten participants (15.9%) were willing to participate in a placebo-controlled trial. Being married was associated with decreased odds of participating (OR: 0.2; 95% CI, 0.05 to 0.8; P = 0.03), while the main barriers were a lack of information about the procedure, reassurance of a positive outcome with participation, and concerns about the risks and benefits of placebo surgery.

Conclusions: A minority of patients with lumbar spinal stenosis were willing to participate in a placebo-controlled trial of surgery. The identified barriers indicate that educating eligible patients about: the need for placebo-surgical trials, the personal risks and benefits of participation, and the importance and potential benefits of placebo trials to others, may be crucial to ensure adequate recruitment into the placebo-controlled surgical trial. Conclusions should be read cautiously however, given the small sample size present in this study.
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http://dx.doi.org/10.1016/j.heliyon.2019.e01683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529717PMC
May 2019

Management of low back pain in Australian emergency departments.

BMJ Qual Saf 2019 10 4;28(10):826-834. Epub 2019 Jun 4.

Institute for Musculoskeletal Health, University of Sydney School of Public Health, Sydney, New South Wales, Australia.

Background: To describe the diagnoses of people who present to the emergency department (ED) with low back pain (LBP), the proportion of people with a lumbar spine condition who arrived by ambulance, received imaging, opioids and were admitted to hospital; and to explore factors associated with these four outcomes.

Methods: In this retrospective study, we analysed electronic medical records for all adults presenting with LBP at three Australian EDs from January 2016 to June 2018. Outcomes included discharge diagnoses and key aspects of care (ambulance transport, lumbar spine imaging, provision of opioids, admission). We explored factors associated with these care outcomes using multilevel mixed-effects logistic regression models and reported data as ORs.

Results: There were 14 024 presentations with a 'visit reason' for low back pain, of which 6393 (45.6%) had a diagnosis of a lumbar spine condition. Of these, 31.4% arrived by ambulance, 23.6% received lumbar imaging, 69.6% received opioids and 17.6% were admitted to hospital. Older patients (OR 1.79, 95% CI 1.56 to 2.04) were more likely to be imaged. Opioids were less used during working hours (OR 0.81, 95% CI 0.67 to 0.98) and in patients with non-serious LBP compared with patients with serious spinal pathology (OR 1.65, 95% CI 1.07 to 2.55). Hospital admission was more likely to occur during working hours (OR 1.74, 95% CI 1.48 to 2.05) and for those who arrived by ambulance (OR 2.98, 95% CI 2.53 to 3.51).

Conclusion: Many ED presentations of LBP were not due to a lumbar spine condition. Of those that were, we noted relatively high rates of lumbar imaging, opioid use and hospital admission.
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http://dx.doi.org/10.1136/bmjqs-2019-009383DOI Listing
October 2019

Transcutaneous electric nerve stimulation (TENS) for acute low back pain: systematic review.

Scand J Pain 2019 04;19(2):225-233

Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia.

Background and aims There has been no comprehensive evaluation of the efficacy of transcutaneous electric nerve stimulation (TENS) for acute low back pain (LBP). The aim of this systematic review was to investigate the efficacy and safety of TENS for acute LBP. Methods We searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL and PsycINFO (inception to May 2018) for randomised placebo controlled trials. The primary outcome measure was pain relief in the immediate term (within 2-weeks of administration) assessed using the 100 mm visual analogue scale. A mean difference of at least 10 points on the 100-point pain scale was considered clinically significant. Methodological quality of the eligible studies was assessed using the PEDro scale and overall quality assessment rating was assessed using GRADE. Results Three placebo controlled studies (n = 192) were included. One low quality trial (n = 63) provides low quality evidence that ~30 min treatment with TENS in an emergency-care setting provides clinically worthwhile pain relief for moderate to severe acute LBP in the immediate term compared with sham TENS [Mean Difference (MD) - 28.0 (95% CI - 32.7, -23.3)]. Two other studies which administered a course of TENS over 4-5 weeks, in more usual settings provide inconclusive evidence; MD -2.75 (95% CI -11.63, 6.13). There was limited data on adverse events or long term follow-up. Conclusions The current evidence is insufficient to support or dismiss the use of TENS for acute LBP. Implications There is insufficient evidence to guide the use of TENS for acute LBP. There is low quality evidence of moderate improvements in pain with a short course of TENS (~30 min) during emergency transport of patients to the hospital. Future research should evaluate whether TENS has an opioid sparing role in the management of acute LBP.
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http://dx.doi.org/10.1515/sjpain-2018-0124DOI Listing
April 2019

Paracetamol versus placebo for knee and hip osteoarthritis.

Cochrane Database Syst Rev 2019 Feb 25;2:CD013273. Epub 2019 Feb 25.

Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Reserve Road St Leonards, Sydney, New South Wales, Australia, 2065.

Background: Paracetamol (acetaminophen) is vastly recommended as the first-line analgesic for osteoarthritis of the hip or knee. However, there has been controversy about this recommendation given recent studies have revealed small effects of paracetamol when compared with placebo. Nonetheless, past studies have not systematically reviewed and appraised the literature to investigate the effects of this drug on specific osteoarthritis sites, that is, hip or knee, or on the dose used.

Objectives: To assess the benefits and harms of paracetamol compared with placebo in the treatment of osteoarthritis of the hip or knee.

Search Methods: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, AMED, CINAHL, Web of Science, LILACS, and International Pharmaceutical Abstracts to 3 October 2017, and ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP) portal on 20 October 2017.

Selection Criteria: We included randomised controlled trials comparing paracetamol with placebo in adults with osteoarthritis of the hip or knee. Major outcomes were pain, function, quality of life, adverse events and withdrawals due to adverse events, serious adverse events, and abnormal liver function tests.

Data Collection And Analysis: Two review authors used standard Cochrane methods to collect data, and assess risk of bias and quality of the evidence. For pooling purposes, we converted pain and physical function (Western Ontario and McMaster Universities Osteoarthritis Index function) scores to a common 0 (no pain or disability) to 100 (worst possible pain or disability) scale.

Main Results: We identified 10 randomised placebo-controlled trials involving 3541 participants with hip or knee osteoarthritis. The paracetamol dose varied from 1.95 g/day to 4 g/day, and the majority of trials followed participants for three months only. Most trials did not clearly report randomisation and concealment methods and were at unclear risk of selection bias. Trials were at low risk of performance, detection, and reporting bias.At 3 weeks' to 3 months' follow-up, there was high-quality evidence that paracetamol provided no clinically important improvements in pain and physical function. Mean reduction in pain was 23 points (0 to 100 scale, lower scores indicated less pain) with placebo and 3.23 points better (5.43 better to 1.02 better) with paracetamol, an absolute reduction of 3% (1% better to 5% better, minimal clinical important difference 9%) and relative reduction of 5% (2% better to 8% better) (seven trials, 2355 participants). Physical function improved by 12 points on a 0 to 100 scale (lower scores indicated better function) with placebo and was 2.9 points better (0.95 better to 4.89 better) with paracetamol, an absolute improvement of 3% (1% better to 5% better, minimal clinical important difference 10%) and relative improvement of 5% (2% better to 9% better) (7 trials, 2354 participants).High-quality evidence from eight trials indicated that the incidence of adverse events was similar between groups: 515/1586 (325 per 1000) in the placebo group versus 537/1666 (328 per 1000, range 299 to 360) in the paracetamol group (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.92 to 1.11). There was less certainty (moderate-quality evidence) around the risk of serious adverse events, withdrawals due to adverse events, and the rate of abnormal liver function tests, due to wide CIs or small event rates, indicating imprecision. Seventeen of 1480 (11 per 1000) people treated with placebo and 28/1729 (16 per 1000, range 8 to 29) people treated with paracetamol experienced serious adverse events (RR 1.36, 95% CI 0.73 to 2.53; 6 trials). The incidence of withdrawals due to adverse events was 65/1000 participants in with placebo and 77/1000 (range 59 to 100) participants with paracetamol (RR 1.19, 95% CI 0.91 to 1.55; 7 trials). Abnormal liver function occurred in 18/1000 participants treated with placebo and 70/1000 participants treated with paracetamol (RR 3.79, 95% CI 1.94 to 7.39), but the clinical importance of this effect was uncertain. None of the trials reported quality of life.Subgroup analyses indicated that the effects of paracetamol on pain and function did not differ according to the dose of paracetamol (3.0 g/day or less versus 3.9 g/day or greater).

Authors' Conclusions: Based on high-quality evidence this review confirms that paracetamol provides only minimal improvements in pain and function for people with hip or knee osteoarthritis, with no increased risk of adverse events overall. Subgroup analysis indicates that the effects on pain and function do not differ according to the dose of paracetamol. Due to the small number of events, we are less certain if paracetamol use increases the risk of serious adverse events, withdrawals due to adverse events, and rate of abnormal liver function tests.Current clinical guidelines consistently recommend paracetamol as the first-line analgesic medication for hip or knee osteoarthritis, given its low absolute frequency of substantive harm. However, our results call for reconsideration of these recommendations.
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http://dx.doi.org/10.1002/14651858.CD013273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388567PMC
February 2019

Treatment Effect Sizes of Mechanical Diagnosis and Therapy for Pain and Disability in Patients With Low Back Pain: A Systematic Review.

J Orthop Sports Phys Ther 2019 Apr 13;49(4):219-229. Epub 2019 Feb 13.

Background: Mechanical Diagnosis and Therapy (MDT) is a treatment-based classification system founded on 3 core principles: classification into diagnostic syndromes, classification-based intervention, and appropriate application of force. Many randomized controlled trials have investigated the efficacy of MDT for low back pain; however, results have varied. The inconsistent delivery of MDT across trials may explain the different findings.

Objectives: To compare treatment effect sizes for pain or disability between trials that delivered MDT consistent with the core principles of the approach and trials that met some or none of these principles.

Methods: In this systematic review, databases were searched from inception to June 2018 for studies that delivered MDT compared to nonpharmacological, conservative control interventions in patients with low back pain and reported outcomes of pain or disability. Studies were classified as "adherent" (meeting the core principles of MDT) or "nonadherent" (using some or none of the principles of MDT). Data were extracted by 2 independent reviewers. Meta-regression procedures were used to analyze the effect of delivery mode on clinical outcomes, adjusting for covariates of symptom duration (less than or greater than 3 months) and control intervention (minimal or active).

Results: Studies classified as adherent to the MDT approach showed greater reductions in pain and disability of 15.0 (95% confidence interval: 7.3, 22.7) and 11.7 (95% confidence interval: 5.4, 18.0) points, respectively, on a 100-point scale compared to nonadherent trials.

Conclusion: This review provides preliminary evidence that treatment effects of MDT are greater when the core principles are followed.

Level Of Evidence: Therapy, level 1a. J Orthop Sports Phys Ther 2019;49(4):219-229. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8734.
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April 2019

Implementation of an evidence-based model of care for low back pain in emergency departments: protocol for the Sydney Health Partners Emergency Department (SHaPED) trial.

BMJ Open 2018 04 19;8(4):e019052. Epub 2018 Apr 19.

Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.

Introduction: Patients with low back pain often seek care in emergency departments, but the problem is that many patients receive unnecessary or ineffective interventions and at the same time miss out on the basics of care, such as advice on self-management. This pattern of care has important consequences for the healthcare system (expensive and inefficient) and for patients (poor health outcomes). We hypothesised that the implementation of an evidence-based model of care for low back pain will improve emergency care by reducing inappropriate overuse of tests and treatments and improving patient outcomes.

Methods And Analysis: A stepped-wedge cluster randomised controlled trial will be conducted to implement and evaluate the use of the Agency for Clinical Innovation (ACI) model of care for acute low back pain at four emergency departments in New South Wales, Australia. Clinician participants will be emergency physicians, nurses and physiotherapists. Codes from the Systematised Nomenclature of Medicine-Clinical Terms-Australian version will be used to identify low back pain presentations. The intervention, targeting emergency clinicians, will comprise educational materials and seminars and an audit and feedback approach. Health service delivery outcomes are routinely collected measures of imaging (primary outcome), opioid use and inpatient admission. A random subsample of 200 patient participants from each trial period will be included to measure patient outcomes (pain intensity, physical function, quality of life and experience with emergency service). The effectiveness of the intervention will be assessed by comparing the postintervention period with the retrospective baseline control period.

Ethics And Dissemination: The study received ethical approval from the Sydney Local Health District (Royal Prince Alfred Hospital zone) Ethics Committee (X17-0043). The results of this study will be published in peer-reviewed journals and presented at international conferences.

Trial Registration Number: Australia New Zealand Clinical Trials Registry: ACTRN 12617001160325.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914780PMC
April 2018

Limited evidence for screening for serious pathologies using red flags in patients with low back pain presenting to the emergency department.

Emerg Med Australas 2018 06 15;30(3):436-437. Epub 2018 Apr 15.

School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1111/1742-6723.12984DOI Listing
June 2018

Can obesity and physical activity predict outcomes of elective knee or hip surgery due to osteoarthritis? A meta-analysis of cohort studies.

BMJ Open 2018 02 27;8(2):e017689. Epub 2018 Feb 27.

Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.

Objective: The aim of this study was to systematically review the literature to identify whether obesity or the regular practice of physical activity are predictors of clinical outcomes in patients undergoing elective hip and knee arthroplasty due to osteoarthritis.

Design: Systematic review and meta-analysis.

Data Source And Eligibility Criteria: A systematic search was performed on the Medline, CINAHL, EMBASE and Web of Science electronic databases. Longitudinal cohort studies were included in the review. To be included, studies needed to have assessed the association between obesity or physical activity participation measured at baseline and clinical outcomes (ie, pain, disability and adverse events) following hip or knee arthroplasty.

Data Extraction: Two independent reviewers extracted data on pain, disability, quality of life, obesity, physical activity and any postsurgical complications.

Results: 62 full papers were included in this systematic review. From these, 31 were included in the meta-analyses. Our meta-analysis showed that compared to obese participants, non-obese participants report less pain at both short term (standardised mean difference (SMD) -0.43; 95% CI -0.67 to -0.19; P<0.001) and long term post-surgery (SMD -0.36; 95% CI -0.47 to -0.24; P<0.001), as well as less disability at long term post-surgery (SMD -0.32; 95% CI -0.36 to -0.28; P<0.001). They also report fewer postsurgical complications at short term (OR 0.48; 95% CI 0.25 to 0.91; P<0.001) and long term (OR 0.55; 95% CI 0.41 to 0.74; P<0.001) along with less postsurgical infections after hip arthroplasty (OR 0.33; 95% CI 0.18 to 0.59; P<0.001), and knee arthroplasty (OR 0.42; 95% CI 0.23 to 0.78; P=0.006).

Conclusions: Presurgical obesity is associated with worse clinical outcomes of hip or knee arthroplasty in terms of pain, disability and complications in patients with osteoarthritis. No impact of physical activity participation has been observed.

Prospero Registration Number: CRD42016032711.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855486PMC
February 2018

Clinician, patient and general public beliefs about diagnostic imaging for low back pain: protocol for a qualitative evidence synthesis.

BMJ Open 2018 02 10;8(2):e019470. Epub 2018 Feb 10.

Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia.

Introduction: Little is known about how to reduce unnecessary imaging for low back pain. Understanding clinician, patient and general public beliefs about imaging is critical to developing strategies to reduce overuse.

Objective: To synthesise qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.

Methods And Analysis: We will perform a qualitative evidence synthesis of relevant qualitative research exploring clinician, patient and general public beliefs about diagnostic imaging for low back pain. Exclusions will be studies not using qualitative methods and studies not published in English. Studies will be identified using sensitive search strategies in MEDLINE, EMBASE, CINAHL, AMED and PsycINFO. Two reviewers will independently apply inclusion and exclusion criteria, extract data, and use the Critical Appraisal Skills Programme quality assessment tool to assess the quality of included studies. To synthesise the data we will use a narrative synthesis approach that involves developing a theoretical model, conducting a preliminary synthesis, exploring relations in the data, and providing a structured summary. We will code the data using NVivo. At least two reviewers will independently apply the thematic framework to extracted data. Confidence in synthesis findings will be evaluated using the GRADE Confidence in the Evidence from Reviews of Qualitative Research tool.

Ethics And Dissemination: Ethical approval is not required to conduct this review. We will publish the results in a peer-reviewed journal.

Prospero Registration Number: CRD42017076047.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829893PMC
February 2018

Managing non-serious low back pain in the emergency department: Time for a change?

Emerg Med Australas 2018 Apr 16;30(2):279-282. Epub 2017 Nov 16.

School of Public Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.

Low back pain is a common condition seen in the ED. However, its management in this setting has received relatively little attention and there have been few efforts to develop strategies to improve emergency care of low back pain. In order to ensure that care is appropriately delivered for low back pain patients in the ED, emergency physicians must understand issues of providing low-value care and consider potential solutions to the problem. In this paper, we describe the usual emergency care provided for non-serious low back pain and present possible strategies for restructuring ED practice and approaches for changing physician and patient behaviour. A better understanding of how non-serious low back pain is currently being managed and discussion on how to provide evidence-based care according to current guideline recommendations will help emergency physicians improve the value of care for these patients.
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http://dx.doi.org/10.1111/1742-6723.12903DOI Listing
April 2018

Smartphone apps for the self-management of low back pain: A systematic review.

Best Pract Res Clin Rheumatol 2016 12 25;30(6):1098-1109. Epub 2017 May 25.

School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia; Centre for Pain, Health and Lifestyle, Australia.

Guidelines for low back pain (LBP) often recommend the use of self-management such as unsupervised exercise, booklets, and online education. Another potentially useful way for patients to self-manage LBP is by using smartphone applications (apps). However, to date, there has been no rigorous evaluation of LBP apps and no guidance for consumers on how to select high-quality, evidence-based apps. This chapter reviews smartphone apps for the self-management of LBP and evaluates their content quality and whether they recommend evidence-based interventions. This chapter shows that generally app developers are selecting interventions that are endorsed by guidelines, although their quality is low. There are many apps available for the self-management of LBP, but their effectiveness in improving patient outcomes has not been rigorously assessed. App developers need to work closely with healthcare professionals, researchers, and patients to ensure app content is accurate, evidence based, and engaging.
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http://dx.doi.org/10.1016/j.berh.2017.04.002DOI Listing
December 2016

Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis.

Br J Sports Med 2018 Feb 10;52(3):167-175. Epub 2017 Oct 10.

Department of Rheumatology, Royal North Shore Hospital, St Leonards, Australia.

Objective: To investigate the efficacy and safety of dietary supplements for patients with osteoarthritis.

Design: An intervention systematic review with random effects meta-analysis and meta-regression.

Data Sources: MEDLINE, EMBASE, Cochrane Register of Controlled Trials, Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature were searched from inception to April 2017.

Study Eligibility Criteria: Randomised controlled trials comparing oral supplements with placebo for hand, hip or knee osteoarthritis.

Results: Of 20 supplements investigated in 69 eligible studies, 7 (collagen hydrolysate, passion fruit peel extract, extract, extract, curcumin, pycnogenol and L-carnitine) demonstrated large (effect size >0.80) and clinically important effects for pain reduction at short term. Another six (undenatured type II collagen, avocado soybean unsaponifiables, methylsulfonylmethane, diacerein, glucosamine and chondroitin) revealed statistically significant improvements on pain, but were of unclear clinical importance. Only green-lipped mussel extract and undenatured type II collagen had clinically important effects on pain at medium term. No supplements were identified with clinically important effects on pain reduction at long term. Similar results were found for physical function. Chondroitin demonstrated statistically significant, but not clinically important structural improvement (effect size -0.30, -0.42 to -0.17). There were no differences between supplements and placebo for safety outcomes, except for diacerein. The Grading of Recommendations Assessment, Development and Evaluation suggested a wide range of quality evidence from very low to high.

Conclusions: The overall analysis including all trials showed that supplements provided moderate and clinically meaningful treatment effects on pain and function in patients with hand, hip or knee osteoarthritis at short term, although the quality of evidence was very low. Some supplements with a limited number of studies and participants suggested large treatment effects, while widely used supplements such as glucosamine and chondroitin were either ineffective or showed small and arguably clinically unimportant treatment effects. Supplements had no clinically important effects on pain and function at medium-term and long-term follow-ups.
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http://dx.doi.org/10.1136/bjsports-2016-097333DOI Listing
February 2018

Can Recurrence After an Acute Episode of Low Back Pain Be Predicted?

Phys Ther 2017 Sep;97(9):889-895

Institute of Bone and Joint Research, Sydney Medical School, The University of Sydney, Sydney, Australia.

Background: Although recurrence is common after an acute episode of low back pain, estimates of recurrence rates vary widely and predictors of recurrence remain largely unknown.

Objective: The purposes of the study were to determine the 1-year incidence of recurrence in participants who recovered from an acute episode of low back pain and to identify predictors of recurrence.

Design: The design was an inception cohort study nested in a case-crossover study.

Methods: For 12 months, 832 of the 999 participants who initially presented to primary care within the first 7 days of an episode of low back pain were followed. Of these participants, 469 recovered (1 month pain free) from the index episode within 6 weeks and were included in this study. Recurrence was defined as a new episode lasting more than 1 day, or as an episode of care seeking. Putative predictors were assessed at baseline and chosen a priori. Multivariable regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI).

Results: The 1-year incidence of recurrence of low back pain was 33%, and the 1-year incidence of recurrence of low back pain with care seeking was 18%. Participants reporting more than 2 previous episodes of low back pain had increased odds of future recurrences (OR = 3.18, CI = 2.11-4.78). This factor was also associated with recurrent episodes that led to care seeking (OR = 2.87, CI = 1.73-4.78). No other factors were associated with recurrences.

Limitations: There are limitations inherent in reliance on recall.

Conclusions: After an acute episode of low back pain, one-third of patients will experience a recurrent episode, and approximately half of those will seek care. Experiencing more than 2 previous episodes of low back pain triples the odds of a recurrence within 1 year.
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September 2017

Early comprehensive physiotherapy after lumbar spine surgery (PEDro synthesis).

Br J Sports Med 2018 Jan 22;52(2):96-97. Epub 2017 Aug 22.

Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.

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January 2018

A longitudinal study of the influence of comorbidities and lifestyle factors on low back pain in older men.

Pain 2017 08;158(8):1571-1576

School of Public Health, The University of Sydney, Sydney, Australia.

Older adults are largely under-represented in low back pain (LBP) research. In light of the ageing population, it is crucial to understand the influence of comorbidities and lifestyle factors on the risk and prognosis of LBP in older adults. The aims of this study were to describe the course of LBP in older men; to investigate whether comorbidities/lifestyle factors can predict the course of LBP in older men; to assess if comorbidities/lifestyle factors increase the risk of developing LBP in older men. The study sample comprised 1685 older men living in suburban Sydney, Australia. Low back pain, sociodemographic measures, lifestyle factors, and comorbidities were assessed. Of the 1012 men with LBP at baseline, 58% still reported having pain at the 24-month follow-up. Of those without pain at baseline (n = 673), 28% reported pain at follow-up. The odds of persistent pain at 24 months increased with each additional alcoholic drink/wk (odds ratio [OR] = 1.10, 95% confidence interval [CI]: 1.01-1.22; P = 0.03) and each additional unit of body mass index (OR = 1.28, 95% CI: 1.04-1.60; P = 0.02), but reduced for men who speak English at home (OR = 0.58, 95% CI: 0.35-0.96; P = 0.03). In older men, free of LBP at baseline (n = 673), for every additional comorbidity there was an increased risk of developing LBP (OR = 1.17, 95% CI: 1.00-1.37; P = 0.05). These results demonstrate the influence of lifestyle factors and comorbidities on LBP in older men and suggest that the consideration of these issues in management may improve outcomes.
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August 2017

Trends, Complications, and Costs for Hospital Admission and Surgery for Lumbar Spinal Stenosis.

Spine (Phila Pa 1976) 2017 Nov;42(22):1737-1743

The George Institute for Global Health & Institute of Bone and Joint Research, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.

MINI: Trends in lumbar spinal stenosis surgery are largely unknown outside of the United States. This population-based health record linkage study revealed that complex fusion surgery had a four-fold increase from 2003-2013 in Australia. This surgical procedure increased the risk of complications and resource use compared with decompression surgery alone.

Study Design: Population-based health record linkage study.

Objective: The aim of this study was to determine trends in hospital admissions and surgery for lumbar spinal stenosis, as well as complications and resource use in Australia.

Summary Of Background Data: In the United States, rates of decompression surgery have declined, whereas those of fusion have increased. It is unclear whether this trend is also happening elsewhere.

Methods: We included patients 18 years and older admitted to a hospital in New South Wales between 2003 and 2013 who were diagnosed with lumbar spinal stenosis. We investigated the rates of hospital admission and surgical procedures, as well as hospital costs, length of hospital stay, and complications. Surgical procedures were: decompression alone, simple fusion (one to two disc levels, single approach), and complex fusion (three or more disc levels or a combined posterior and anterior approach).

Results: The rates of decompression alone increased from 19.0 to 22.1 per 100,000 people. Simple fusion rates increased from 1.3 to 2.8 per 100,000 people, whereas complex fusion increased from 0.6 to 2.4 per 100,000 people. The odds of major complications for complex fusion compared with decompression alone was 4.1 (95% confidence interval [CI]: 1.7-10.1), although no significant difference was found for simple fusion (odds ratio 2.0, 95% CI: 0.7-6.1). Mean hospital costs with decompression surgery were AU $12,168, whereas simple and complex fusion cost AU $30,811 and AU $32,350, respectively.

Conclusion: In Australia, decompression rates for lumbar spinal stenosis increased from 2003 to 2013. The fastest increasing surgical procedure was complex fusion. This procedure increased the risk of major complications and resource, although recent evidence suggest fusion provides no additional benefits to the traditional decompression surgery.

Level Of Evidence: 3.
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November 2017