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Health care has significant environmental impact. We performed a scoping review to map what is known about the environmental impact of health care for musculoskeletal conditions. We included published papers of any design that measured or discussed environmental impact of health care or health support services for any musculoskeletal condition in terms of climate change or global warming (e.g., greenhouse gas emissions it produces). We searched MEDLINE and Embase from inception to 2 May 2022 using keywords for environmental health and musculoskeletal conditions, and performed keyword searches using Google and Google Scholar. Two independent reviewers screened studies. One author independently charted data, verified by a second author. A narrative synthesis was performed. Of 12,302 publications screened and 73 identified from other searches, 122 full-text articles were assessed for eligibility, and 49 were included (published 1994 to 2022). Of 24 original research studies, 11 measured environmental impact relating to climate change in orthopaedics (n = 10), and medical aids for the knee (n = 1), one measured energy expenditure of laminar versus turbulent airflow ventilation systems in operating rooms during simulated hip replacements and 12 measured waste associated with orthopaedic surgery but did not relate waste to greenhouse gas emissions or environmental effects. Twenty-one editorials described a need to reduce environmental impact of orthopaedic surgery (n = 9), physiotherapy (n = 9), podiatry (n = 2) or occupational therapy (n = 1). Four narrative reviews discussed sustainability relating to hand surgery (n = 2), orthopaedic surgery (n = 1) and orthopaedic implants (n = 1). Despite an established link between health care and greenhouse gas emissions we found limited empirical data estimating the impact of musculoskeletal health care on the environment. These data are needed to determine whether actions to lower the carbon footprint of musculoskeletal health care should be a priority and to identify those aspects of care that should be prioritised.

BackgroundTo 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.MethodsIn 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.ResultsThere 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).ConclusionMany 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.

BackgroundPain medicines are widely prescribed by general practitioners (GPs) when managing people with low back pain (LBP), but little is known about what drives decisions to prescribe these medicines.ObjectivesThe aim of this study was to investigate what influences GPs’ decision to prescribe pain medicines for LBP.DesignQualitative study with in-depth interviews.SettingAustralian primary care.ParticipantsWe interviewed 25 GPs practising in Australia experienced in managing LBP (mean (SD) age 53.4 (9.1) years, mean (SD) years of experience: 24.6 (9.3), 36% female). GPs were provided three vignettes describing common LBP presentations (acute exacerbation of chronic LBP, subacute sciatica and chronic LBP) and were asked to think aloud how they would manage the cases described in the vignettes.Data analysisWe summarised GP’s choices of pain medicines for each vignette using content analysis and used framework analysis to investigate factors that affected GP’s decision-making.ResultsGPs more commonly prescribed opioid analgesics. Anticonvulsants and antidepressants were also commonly prescribed depending on the presentation described in the vignette. GP participants made decisions about what pain medicines to prescribe for LBP largely based on previous experiences, including their own personal experiences of LBP, rather than guidelines. The choice of pain medicine was influenced by a range of clinical factors, more commonly the patient’s pathoanatomical diagnosis. While many adhered to principles of judicious use of pain medicines, polypharmacy scenarios were also common. Concerns about drug-seeking behaviour, adverse effects, stigma around opioid analgesics and pressure from regulators also shaped their decision-making process.ConclusionsWe identified several aspects of decision-making that help explain the current profile of pain medicines prescribed for LBP by GPs. Themes identified by our study could inform future implementation strategies to improve the quality use of medicines for LBP.

ObjectivesTo 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.SettingWe performed a content analysis of qualitative data collected in a randomised experiment.Participants2237 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 outcomesAfter receiving the education, participants answered two questions regarding (1) words or feelings evoked by the education and (2) treatments they felt were needed.Results2232 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.ConclusionParticipants 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 numberAustralia New Zealand Clinical Trials Registry (ACTRN12623000197639).

QuestionWhat is the effect of Choosing Wisely recommendations on physiotherapists’ intentions to refer for imaging and use electrotherapy for low back pain?DesignThree-arm parallel-group online randomised controlled trial.ParticipantsPhysiotherapists who treat people with low back pain.InterventionParticipants 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 measuresPrimary 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.Results723 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.ConclusionOur 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.

Background Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain. Methods We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively. Results We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections). Conclusions Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.

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.

ObjectivesTo describe the prevalence and patterns of opioid analgesic and pain medicine dispenses, and the impact of up-scheduling of low-dose (≤15 mg) codeine-containing products to Australians with accepted workers’ compensation time loss claims for musculoskeletal conditions between 2010 and 2019.DesignInterrupted time series.SettingWorkers’ compensation scheme in Victoria, Australia.PopulationAustralians with accepted workers’ compensation time loss claims for musculoskeletal conditions between 2010 and 2019.Main outcome measuresNumber and proportion of workers dispensed pain medicines in the first year of claim and the monthly number, percentage of pain medicine dispenses and mean morphine equivalent dispense dose.ResultsNearly one-third (28.4%, n=22 807) of our sample of 80 324 workers were dispensed any opioid in the first year since the workers’ compensation insurer received their claim. There were no significant step or trend changes in the number or percentage of pain medicines dispensed of up-scheduled low-dose codeine. Only 2.9% of workers were ever dispensed up-scheduled low-dose codeine, specifically 2.5% after up-scheduling (1 February 2018). After up-scheduling of low-dose codeine, workers were more likely to be dispensed opioids (excluding codeine) (prevalence ratio (PR) 1.21, 99% CI 1.13, 1.31) or other pain medicines (eg, pregabalin, paracetamol) (PR 1.11, 99% CI 1.03, 1.19) compared with the year prior. There was a significant 28.5% (99% CI 16.3, 41.9) step increase (ie, increase immediately after up-scheduling) in high-dose (>15 mg) codeine with a significant trend decrease (−1.3%, 99% CI −2.5, –0.2).ConclusionUp-scheduling low-dose codeine to prescription-only medicines did not significantly change the dispensing of low-dose codeine-containing products to workers with accepted workers’ compensation time loss claims for musculoskeletal conditions.

Background Infographics have become an increasingly popular method to present research findings and increase the attention research receives. As many scientific journals now use infographics to boost the visibility and uptake of the research they publish, infographics have become an important tool for medical education. It is unknown whether such infographics convey the key characteristics that are needed to make useful interpretations of the data such as an adequate description of the study population, interventions, comparators and outcomes; methodological limitations; and numerical estimates of benefits and harms. This study described whether infographics published in peer-reviewed health and medical research journals contain key characteristics that are needed to make useful interpretations of clinical research. Methods In this cross-sectional study, we identified peer-reviewed journals listed in the top quintile of 35 unique fields of medicine and health research listed in the Journal Citation Reports database. Two researchers screened journals for the presence of infographics. We defined an infographic as a graphical visual representation of research findings. We extracted data from a sample of two of the most recent infographics from each journal. Outcomes were the proportion of infographics that reported key characteristics such as study population, interventions, comparators and outcomes, benefits, harms, effect estimates with measures of precision, between-group differences and conflicts of interest; acknowledged risk of bias, certainty of evidence and study limitations; and based their conclusions on the study’s primary outcome. Results We included 129 infographics from 69 journals. Most infographics described the population (81%), intervention (96%), comparator (91%) and outcomes (94%), but fewer contained enough information on the population (26%), intervention (45%), comparator (20%) and outcomes (55%) for those components of the study to be understood without referring to the main paper. Risk of bias was acknowledged in only 2% of infographics, and none of the 69 studies that had declared a conflict of interest disclosed it in the infographics. Conclusions Most infographics do not report sufficient information to allow readers to interpret study findings, including the study characteristics, results, and sources of bias. Our results can inform initiatives to improve the quality of the information presented in infographics.

ObjectivesExplore how people perceive different labels for rotator cuff disease in terms of words or feelings evoked by the label and treatments they feel are needed.SettingWe performed a content analysis of qualitative data collected in a six-arm, online randomised controlled experiment.Participants1308 people with and without shoulder pain read a vignette describing a patient with rotator cuff disease and were randomised to one of six labels: subacromial impingement syndrome, rotator cuff tear, bursitis, rotator-cuff-related shoulder pain, shoulder sprain and episode of shoulder pain.Primary and secondary outcomesParticipants answered two questions (free-text response) about: (1) words or feelings evoked by the label; (2) what treatments they feel are needed. Two researchers iteratively developed coding frameworks to analyse responses.Results1308/1626 (80%) complete responses for each question were analysed. Psychological distress (21%), uncertainty (22%), serious condition (15%) and poor prognosis (9%) were most often expressed by those labelled with subacromial impingement syndrome. For those labelled with a rotator cuff tear, psychological distress (13%), serious condition (9%) and poor prognosis (8%) were relatively common, while minor issue was expressed least often compared with the other labels (5%). Treatment/investigation and surgery were common among those labelled with a rotator cuff tear (11% and 19%, respectively) and subacromial impingement syndrome (9% and 10%) compared with bursitis (7% and 5%).ConclusionsWords or feelings evoked by certain labels for rotator cuff disease and perceived treatment needs may explain why some labels drive management preferences towards surgery and imaging more than others.