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Background Imaging is overused in the management of low back pain (LBP). Interventions designed to decrease non-indicated imaging have predominantly targeted practitioner education alone; however, these are typically ineffective. Barriers to reducing imaging have been identified for both patients and practitioners. Interventions aimed at addressing barriers in both these groups concurrently may be more effective. The Behaviour Change Wheel provides a structured framework for developing implementation interventions to facilitate behavioural change. The aim of this study was to develop an implementation intervention aiming to reduce non-indicated imaging for LBP, by targeting both general medical practitioner (GP) and patient barriers concurrently. Methods The Behaviour Change Wheel was used to identify the behaviours requiring change, and guide initial development of an implementation intervention. Preliminary testing of the intervention was performed with: 1) content review by experts in the field; and 2) qualitative analysis of semi-structured interviews with 10 GPs and 10 healthcare consumers, to determine barriers and facilitators to successful implementation of the intervention in clinical practice. Results informed further development of the implementation intervention. Results Patient pressure on the GP to order imaging, and the inability of the GP to manage a clinical consult for LBP without imaging, were determined to be the primary behaviours leading to referral for non-indicated imaging. The developed implementation intervention consisted of a purpose-developed clinical resource for GPs to use with patients during a LBP consult, and a GP training session. The implementation intervention was designed to provide GP and patient education, remind GPs of preferred behaviour, provide clinical decision support, and facilitate GP-patient communication. Preliminary testing found experts, GPs, and healthcare consumers were supportive of most aspects of the developed resource, and thought use would likely decrease non-indicated imaging for LBP. Suggestions for improvement of the implementation intervention were incorporated into a final version. Conclusions The developed implementation intervention, aiming to reduce non-indicated imaging for LBP, was informed by behaviour change theory and preliminary testing. Further testing is required to assess feasibility of use in clinical practice, and the effectiveness of the implementation intervention in reducing imaging for LBP, before large-scale implementation can be considered.

The use of quantitative sensory testing (QST) has become more widespread, with increasing focus on describing somatosensory profiles and pain mechanisms. However, the reliability of thermal QST has yet to be established. We systematically searched the literature using key medical databases. Independent reviewers evaluated reliability data using the Quality Appraisal for Reliability Studies checklist. Of the 21 studies we included in this review, we deemed 5 to have high methodological quality. Narrative analysis revealed that estimates of reliability varied considerably, but overall, the reliability of cold and warm detection thresholds ranged from poor to excellent, while heat and cold pain thresholds ranged from fair to excellent. The methodological quality of research investigating the reliability of thermal QST warrants improvement, particularly in terms of appropriate blinding. The results from this review showed considerable variability in the reliability of each thermal QST parameter.

Background Imaging is overused in the management of low back pain, resulting in overdiagnosis, increased healthcare utilisation, and increased costs. Few effective interventions to decrease inappropriate use have been developed and have typically not been developed using behaviour change theory. An intervention to reduce non-indicated imaging for low back pain was developed using behavioural change theory, incorporating a novel low back pain management booklet to facilitate patient education and reassurance. The aim of this study was to assess the adoption and feasibility of use of the developed intervention within clinical practice and to determine appropriate implementation strategies to address identified barriers to use. Methods Fourteen general medical practitioners were recruited and trained to use the booklet with low back pain patients over a minimum 5-month period. Quantitative data on use of the booklet were collected and analysed descriptively. Qualitative data on use of the booklet and training session were collected in general medical practitioner interviews and thematically analysed. Barriers to use were identified and mapped to suitable implementation strategies using the Behaviour Change Wheel. Results Practitioners used the booklet with 73 patients. The booklet was used with 63% of patients presenting with low back pain. Facilitators for using the booklet included patient’s requesting imaging and lower practitioner confidence in managing low back pain. Barriers included accessible storage and remembering to use the booklet. Implementation strategies were identified to increase adoption and feasibility of use, including development of a digital version of the booklet. Conclusions General medical practitioners reported that the low back pain management booklet and training were useful for clinical practice, particularly with patients requesting imaging. Barriers to use were identified and implementation strategies to address these barriers will be incorporated into future effectiveness studies. This study forms one of a series of studies to thoroughly develop and test an intervention to reduce non-indicated imaging for low back pain; a successful intervention would decrease healthcare costs and improve patient management.

Background General medical practitioner (GP) recruitment and subsequent data collection in clinical practice are challenging and may limit successful completion of a large-scale trial. The aim of this study was to assess the feasibility of undertaking a cluster randomised controlled trial to test an intervention to reduce non-indicated imaging for low back pain in general medical practice. Methods A pilot cluster randomised controlled trial was performed, with recruitment of GPs and randomisation of GP clinics. All GPs attended a training session and were asked to record low back pain codes in electronic medical records for any low back pain presentations. Intervention group GPs were trained in the use of a patient education booklet to be used during low back pain patient visits. Control group GPs provided usual care. Outcomes for the proposed trial were collected to determine feasibility. GP recruitment was assessed as the proportion of GPs approached who consented to participate. Low back pain imaging outcomes were collected from electronic medical records (counts of patients presenting with low back pain) and from Australian healthcare administrative (Medicare) data (counts of imaging use). GP compliance with study procedures was assessed and qualitative data reported. Results Thirty-four GP clinics were approached, with four participating (12%). At these clinics, 13/19 (68%) GPs consented to participate, and 10/19 (53%) started the study. Outcome data were collected from medical records for all GPs. Three GPs (30%) withdrew consent to access Medicare data, limiting reporting of imaging outcome measures. Three GPs (30%) self-reported low compliance entering low back pain codes. Conclusions This pilot cluster randomised controlled trial demonstrated the feasibility of many aspects of a full-scale effectiveness study, while also identifying a number of challenges that need to be resolved. Recommendations related to GP recruitment, study compliance, data collection, and outcome measures were made to increase the success of a future trial. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR), Trial ID: ACTRN12619000991112; Registered 11 July 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376973

Abstract Objective This systematic review aimed to 1) assess associations between psychological factors and pain after breast cancer (BC) treatment and 2) determine which preoperative psychological factors predicted pain in the acute, subacute, and chronic time frames after BC surgery. Design A systematic review with meta-analysis. Subjects Women with early-stage BC. Methods The Medline, EMBASE, CINAHL, and Web of Science databases were searched between 1990 and January 2019. Studies that evaluated psychological factors and pain after surgery for early-stage BC were included. Associations between psychological factors and pain, from early after surgery to >12 months after surgery, were extracted. Effect size correlations (r equivalents) were calculated and pooled by using random-effects meta-analysis models. Results Of 4,137 studies, 47 were included (n = 15,987 participants; 26 studies ≤12 months after surgery and 22 studies >12 months after surgery). The majority of the studies had low to moderate risk of bias. Higher preoperative anxiety and depression were weak but significant predictors of pain at all time points up to 12 months (r equivalent: 0.15–0.22). Higher preoperative pain catastrophizing and distress were also weak but significant predictors of pain during the acute (0–7 days) and chronic (3–12 months) periods (r equivalent: 0.10–0.20). For the period >12 months after surgery, weak but significant cross-sectional associations with pain were identified for anxiety, depression, pain catastrophizing, and distress (r equivalents: 0.15, 0.17, 0.25, 0.14, respectively). Conclusion Significant pooled effect size correlations between psychological factors and pain were identified across all time frames. Though weak, these associations should encourage assessment of key psychological factors during preoperative screening and pain assessments at all postoperative time frames.

Wrist fractures are common injuries associated with high disability in the early recovery period. The impact of wrist fractures on safe return to drive is not understood. (1) To compare the proportion of adults who were drivers in car crashes before and after wrist fracture; (2) To examine potential factors (demographic and/or clinical) associated with increased odds of being a driver in a car crash following wrist fracture. Retrospective cohort study. Three state-wide government datasets (MainRoads Western Australia [WA], Hospital Morbidity Data Collection and the Emergency Department Data Collection) were used to obtain and link demographic, clinical and car crash information relating to adults with a wrist fracture sustained between 2008 and 2017. McNemar’s tests were used to compare the proportion of drivers in a car crash within the 2 years prior to and following the fracture date. Multivariable logistic regressions were used to identify if any variables were associated with increased odds of crashing in the post-fracture period. Data relating to 37,107 adults revealed a 3.3% (95% CI 3.0%–3.6%, p < 0.05) decrease in the proportion of drivers in a car crash following wrist fracture, persisting for the entire 2 years post-fracture, when compared to the proportion who crashed before their fracture. Those with more severe wrist fracture injury patterns had 79%(95% CI 1.07–3.0, p = 0.03) higher odds of having a crash in the first 3 months following their injury, compared to those with isolated wrist fracture injuries. These results inform and update return to drive recommendations. The reduced proportion of drivers involved in crashes following wrist fracture persisted for 2 years; longer than the expected physical recovery timeframe. It is important that hand therapists actively educate the sub-group of adults with more severe wrist fracture injury patterns of the increased likelihood of car crash for the 3 months following their fracture. •This the first paper to report on car crashes following wrist fracture.•We provide much needed information to assist with return to drive decision-making.•Those with severe injury had 79% higher odds of crashing in the initial 3-months.•Education is recommended for the sub-group with 3-months of increased crash risk.

IntroductionPain is the dominant symptom of knee osteoarthritis (OA), and recent evidence suggests factors outside of local joint pathology, such as pain sensitisation, can contribute significantly to the pain experience. It is unknown how pain sensitisation influences outcomes from commonly employed interventions such as physiotherapy. The aims of this study are, first, to provide a comprehensive description of the somatosensory characteristics of people with pain associated with knee OA. Second, we will investigate if indicators of pain sensitisation in patients with knee osteoarthritis are predictive of non-response to physiotherapy.Methods and analysisThis is a multicentre prospective cohort study with 140 participants. Eligible patients with moderate to severe symptomatic knee osteoarthritis will be identified at outpatient orthopaedic and rheumatology clinics. A baseline assessment will provide a comprehensive description of the somatosensory characteristics of each participant by means of clinical examination, quantitative sensory testing, and validated questionnaires measuring pain and functional capacity. Participants will then undergo physiotherapy treatment. The primary outcome will be non-response to physiotherapy on completion of the physiotherapy treatment programme as defined by the Osteoarthritis Research Society International treatment responder criteria. A principal component analysis will identify measures related to pain sensitisation to include in the predictive model. Regression analyses will explore the relationship between responder status and pain sensitisation while accounting for confounders.Ethics and disseminationThis study has been approved by St James’ Hospital/AMNCH Research Ethics Committee and by the St Vincent's Healthcare Group Ethics and Medical Research Committee. The results will be presented at international conferences and published in a peer review journal.Trial registration numberNCT02310945.

Since its establishment in 2011, the European Securities and Markets Authority (ESMA) has become a pivotal actor in EU financial market regulation and supervision. Its burgeoning influence extends from the rule-making process to supervisory convergence/coordination to direct supervision. Reflecting the now critical importance of ESMA to how the EU regulates and supervises financial markets, and with ESMA at an inflection point in its evolution, particularly in light of the Commission’s 2017 proposals to reform ESMA and the UK’s withdrawal from the EU, The Age of ESMA maps, contextualises, and examines ESMA’s role and the implications for EU financial market governance.

Moloney expresses how proud he is to take on the event honoring Trinity College Dublin professor Patrick Honohan. He says that Patrick is something of a renaissance figure in the scale, breadth, and depth of his contribution to the Academy and to public life, in Ireland and internationally. He adds that there are few in the Academy who can cross from the groves and towers of academia to ascend to the pinnacle of policy and public life. Patrick has done so with his signature distinction, intellectual heft, generosity of spirit, and commitment to the public interest.

This article examines the setting of the legal regime governing third country access to the UK financial market, in light of the political, market, and legal disruption associated with the UK withdrawal from the EU. It considers the UK reform context and the priority being given to securing UK financial market competitiveness, identifies a related and significant liberalization of the third country regime, and examines the implications for the UK, the EU, and for international financial market access.