Explore the vast range of titles available.

Background Physiotherapists deliver evidence-based guideline recommended treatments only half of the time to patients with musculoskeletal conditions. Physiotherapists’ behaviour in clinical practice are influenced by many cognitive, social, and environmental factors including time and financial pressures. Many initiatives aimed at improving physiotherapists’ uptake of evidence-based care have failed to appreciate the context involved in clinical decisions and clinical practice. Therefore, we aimed to describe: i) opinions toward evidence; ii) how evidence is accessed; iii) factors influencing evidence access; iv) factors influencing evidence application, for physiotherapists working in regional areas. Methods We used a mixed-methods study with online survey and focus groups. We included registered physiotherapists in the survey and physiotherapists practising in regional New South Wales in the focus groups. Quantitative and qualitative data were used to inform all research objectives. We used eight domains of the Transtheoretical Domains Framework to design survey questions. We analysed quantitative and qualitative data in parallel, then integrated both sources through by developing a matrix while considering the Transtheoretical Domains Framework domains to generate themes. Results Fifty-seven physiotherapists participated in the study (survey only n  = 41; focus group only n  = 8; both survey and focus group n  = 8). Participants reported that evidence was important, but they also considered patient expectations, colleagues’ treatment choices, and business demands in clinical decision making. Physiotherapists reported they access evidence on average 30 minutes or less per week. Competing demands like business administration tasks are barriers to accessing evidence. Participants reported that patient expectations were a major barrier to applying evidence in practice. Environmental and systemic factors, like funding structures or incentives for evidence-based care, and social factors, like lacking or having a culture of accountability and mentorship, were reported as both barriers and enablers to evidence application. Conclusions This study provides context to physiotherapists’ opinion, access, and application of evidence in clinical practice. Physiotherapists’ provision of evidence-based care may be improved by enhancing structural support from workplaces to access and apply evidence and exploring discrepancies between physiotherapists’ perceptions of patient expectations and actual patient expectations.

We assessed authors’ language and methods to determine alignment between reported aims, methods, intent, and interpretations in observational studies in spinal pain or osteoarthritis. We searched five databases for observational studies that included people with spinal pain or osteoarthritis published in the last 5 years. We randomized 100 eligible studies, and classified study intent (aims and methods) and interpretations as causal, non-causal, unclear, or misaligned. Overall, 38% of studies were aligned regarding their intent and interpretation (either causally (22%) or non-causally (16%)). 29% of studies’ aims and 29% of study methods were unclear. Intent was misaligned in 16% of studies (where aim differed to method) and 23% of studies had misaligned interpretations (where there were multiple conflicting claims). The most common kind of aim was non-causal (38%), and the most common type of method (39%), intent (38%), and interpretations (35%) was causal. Misalignment and mixed messages are common in observational research of spinal pain and osteoarthritis. More than 6 in 10 observational studies may be uninterpretable, because study intent and interpretations do not align. While causal methods and intent are most common in observational research, authors commonly shroud causal intent in non-causal terminology. •Researchers' interpretations are misaligned with their intent in almost two-thirds of observational studies.•Causal intent and interpretations are most common in observational research.•Researchers often use methods that signal causal intent but use noncausal or ambiguous language to describe their intent.•Researchers commonly use causal language when interpreting their results, even when methods do not signal causal intent.What should change now?•Researchers should align their stated aims, methods, and interpretations.•Researchers should precisely express their aim in observational research.•Researchers should clearly explain their rationale behind study design elements like enrolling a control group or methods like covariate selection and confounding adjustment.•Researchers should unambiguously interpret their results, in alignment with the intent of their study.•End-users should beware that noncausal or ambiguous language is used to shroud causal intent in observational research.

Information to decide whether to have surgery (or not) Patients need a clear appraisal of the evidence, to make an informed decision about whether to have ACL reconstruction (ACLR) or not following ACL injury.2 There is only one published randomised trial comparing the two options; it reported no difference in pain, function or return to preinjury activity levels at 1-year, 2-year and 5-year follow-up.3 Current evidence suggests that the long-term prevalence of osteoarthritis is no difference between patients who receive ACLR compared with those who do not undergo surgery.4 Although factors like a patient’s age and plans to return to sports involving pivoting may predict success of surgery,2 there are individuals who can cope without ACLR after ACL injury.3 4 Part 2—your ACL journey guide: rehabilitation explained The need to ensure quality rehabilitation Regardless of treatment pathway, patients should focus on evidence-based rehabilitation immediately after their ACL injury as their firstline treatment.2 Rehabilitation is key to restoring normal knee function, preventing further knee injury and optimising long-term quality of life.2 Patients should progress through an individualised, criterion-based programme with through three distinct ‘phases’.5 Patients with better functional performance have better long-term outcomes, including lower rates of osteoarthritis.6 Intense rehabilitation is important to optimise outcomes as currently very few patients manage to reach the standard required to return to sport safely.7 8 When to return to play During the final stage of rehabiliation, patients face another complex decision—when are they ready to return to sport? Return to sport should include sport-specific training and underpinned by a battery of performance tests, for example, hop tests.1 5 It is also important that patients feel confident to return to sport before actually returning.1 How to reduce the likelihood of injury Exercise-based injury reduction programmes can reduce the incidence of ACL injuries, but implementation is inconsistent at community level.10 Part of the challenge is choosing between many options and optimising specificity for chosen sports.10 However, there are a few key components of effective programmes, including regular strengthening and neuromuscular challenges like landing and agility practice.10 Clinicians, coaches, patients and parents should understand and communicate the importance of adherence to injury reduction programmes. Evidence-Based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus.

IntroductionLow back pain is one of the most common and burdensome chronic conditions worldwide. Lifestyle factors, such as excess weight, physical inactivity, poor diet and smoking, are linked to low back pain chronicity and disability. There are few high-quality randomised controlled trials that investigate the effects of targeting lifestyle risk factors in people with chronic low back pain.Methods and analysisThe aim of this study is to determine the effectiveness of a Healthy Lifestyle Program (HeLP) for low back pain targeting weight, physical activity, diet and smoking to reduce disability in patients with chronic low back pain compared with usual care. This is a randomised controlled trial, with participants stratified by body mass index, allocated 1:1 to the HeLP intervention or usual physiotherapy care. HeLP involves three main components: (1) clinical consultations with a physiotherapist and dietitian; (2) educational resources; and (3) telephone-based health coaching support for lifestyle risk factors. The primary outcome is disability (Roland Morris Disability Questionnaire) at 26 weeks. Secondary outcomes include pain intensity, weight, quality of life and smoking status. Data will be collected at baseline, and at weeks 6, 12, 26 and 52. Patients with chronic low back pain who have at least one health risk factor (are overweight or obese, are smokers and have inadequate physical activity or fruit and vegetable consumption) will be recruited from primary or secondary care, or the community. Primary outcome data will be analysed by intention to treat using linear mixed-effects regression models. We will conduct three supplementary analyses: causal mediation analysis, complier average causal effects analysis and economic analysis.Ethics and disseminationThis study was approved by the Hunter New England Research Ethics Committee (Approval No 17/02/15/4.05), and the University of Newcastle Human Research Ethics Committee (Ref No H-2017-0222). Outcomes of this trial and supplementary analyses will be disseminated through publications in peer-reviewed journals and conference presentations.Trial registration numberACTRN12617001288314.

Background The disconnect between research and clinical practice leads to research evidence that is often not useful for clinical practice. Practice-based research networks are collaborations between researchers and clinicians aimed at coproducing more useful research. Such networks are rare in the physiotherapy field. We aimed to describe (i) clinicians’ motivations behind, and enablers to, participating in a network, (ii) the process of network establishment and (iii) research priorities for a practice-based network of physiotherapists in the Hunter Region of New South Wales (NSW), Australia that supports research coproduction. Methods We describe the methods and outcomes of the three steps we used to establish the network. Step 1 involved consultation with local opinion leaders and a formative evaluation to understand clinicians’ motivations behind, and enablers to, participating in a network. Step 2 involved establishment activities to generate a founding membership group and codesign a governance model. Step 3 involved mapping clinical problems through a workshop guided by systems thinking theory with local stakeholders and prioritizing research areas. Results Through formative evaluation focus groups, we generated five key motivating themes and three key enablers for physiotherapists’ involvement in the network. Establishment activities led to a founding membership group ( n  = 29, 67% from private practice clinics), a network vision and mission statement, and a joint governance group (9/13 [70%] are private practice clinicians). Our problem-mapping and prioritization process led to three clinically relevant priority research areas with the potential for significant change in practice and patient outcomes. Conclusions Clinicians are motivated to break down traditional siloed research generation and collaborate with researchers to solve a wide array of issues with the delivery of care. Practice-based research networks have promise for both researchers and clinicians in the common goal of improving patient outcomes.

Background This paper describes the statistical analysis plan for a randomised controlled trial of a Healthy Lifestyle Program (HeLP) for low back pain targeting multiple health risks and behaviours, weight, physical activity, diet and smoking, to improve disability. We describe the methods for the main analyses and economic analysis of the trial. Methods and design The trial is a two-arm pragmatic randomised controlled trial comparing the effect of the HeLP intervention to usual care on low back pain disability at 26 weeks. A total of 346 adults with low back pain were recruited from the Newcastle and Hunter region between September 2017 and November 2019 and randomised to either HeLP or usual care. HeLP is a 6-month intervention with participant outcomes measured at weeks 6, 12, 26 and 52 post randomisation. This statistical analysis plan describes data integrity, handling and preparation of data for analyses and methods for analyses. The primary endpoint for the trial is disability at 26 weeks using the 24-item self-report Roland Morris Disability Questionnaire. The primary analysis will follow the intention-to-treat principle using linear mixed regression models. Discussion The statistical analysis plan for this trial was produced to reduce outcome reporting bias arising from knowledge of the study findings. Any deviations will be described and justified in the final report. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12617001288314 . Registered on 6 September 2017.

To assess the reporting quality of exercise interventions from clinical trials of low back pain (LBP). We conducted a systematic review to assess the reporting quality of randomised controlled trials (RCTs) that investigated the effectiveness of exercise interventions for patients with LBP. Five online databases and Clinical Trial Registries were searched (October 2018). We included RCTs that reported interventions for LBP, containing at least 50% exercise. The Template for Intervention Description and Replication (TIDieR) and the Consensus on Exercise Reporting Template (CERT) reporting checklists were then used to assess quality of reporting. 582 trials were eligible for inclusion. Due to the large number of eligible studies, 100 studies were randomly selected for data extraction and coding with the TIDieR and CERT checklists. The random sample was representative of the 582 eligible trials. The overall completeness of reporting (median (IQR)) of TIDieR items was 59.2% (45.5%–72.7%) and CERT was 33.3% (22.2%–52.6%). We found poor overall reporting with both checklists, which has not improved over time or since the introduction of the checklists. More dedicated work is required to address poor reporting of exercise interventions in clinical trials.

ObjectivesTo develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions.DesignWe performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting.SettingAustralian primary care.ParticipantsRegistered physiotherapists who are members of a practice-based research network (n=31).ResultsThe rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application.ConclusionHigh value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

An unhealthy lifestyle is believed to increase the development and persistence of low back pain, but there is uncertainty about whether integrating support for lifestyle risks in low back pain management improves patients' outcomes. To assess the effectiveness of the Healthy Lifestyle Program (HeLP) compared with guideline-based care for low back pain disability. This superiority, assessor-blinded randomized clinical trial was conducted in Australia from September 8, 2017, to December 30, 2020, among 346 participants who had activity-limiting chronic low back pain and at least 1 lifestyle risk (overweight, poor diet, physical inactivity, and/or smoking), referred from hospital, general practice, and community settings. Statistical analysis was performed from January to December 2021. Participants were block randomized to the HeLP intervention (n = 174; 2 postrandomization exclusions) or guideline-based physiotherapy care (n = 172), stratified by body mass index, using a concealed function in REDCap. HeLP integrated healthy lifestyle support with guideline-based care using physiotherapy and dietetic consultations, educational resources, and telephone-based health coaching over 6 months. The primary outcome was low back pain disability (Roland Morris Disability Questionnaire [RMDQ] score; 0-24 scale, where higher scores indicate greater disability) at 26 weeks. Secondary outcomes were weight, pain intensity, quality of life, and smoking. Analyses were performed by intention to treat. We estimated the complier average causal effect (CACE) as sensitivity analyses. The sample of 346 individuals (mean [SD] age, 50.2 [14.4] years; 190 female participants [55%]) had a baseline mean (SD) RMDQ score of 14.7 (5.4) in the intervention group and 14.0 (5.5) in the control group. At 26 weeks, the between-group difference in disability was -1.3 points (95% CI, -2.5 to -0.2 points; P = .03) favoring HeLP. CACE analysis revealed clinically meaningful benefits in disability among compliers, favoring HeLP (-5.4 points; 95% CI, -9.7 to -1.2 points; P = .01). HeLP participants lost more weight (-1.6 kg; 95% CI, -3.2 to -0.0 kg; P = .049) and had greater improvement in quality of life (physical functioning score; 1.8, 95% CI, 0.1-3.4; P = .04) than control participants. Combining healthy lifestyle management with guideline-based care for chronic low back pain led to small improvements in disability, weight, and quality of life compared with guideline-based care alone, without additional harm. Targeting lifestyle risks in the management of chronic low back pain may be considered safe and may offer small additional health benefits beyond current guideline-based care. http://anzctr.org.au Identifier: ACTRN12617001288314.