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Background Routine seeking of imaging for patients with low back pain is not concordant with the evidence-based recommendation that imaging is rarely of diagnostic value. Inappropriate imaging is a waste of resources and can lead to undesirable downstream effects for individuals and health systems. To develop effective strategies to reduce unwarranted referrals for imaging in primary care, we must understand the drivers for, and barriers to, guideline-adherent practice. We explored clinicians’ views to identify the dominant influences on clinicians as they choose to pursue, or avoid, imaging for their patients with low back pain. Methods We interviewed a purposeful sample of 47 primary care clinicians (14 physiotherapists, 18 chiropractors, 15 physicians) throughout Ontario, Canada, with a guide based on the Theoretical Domains Framework (TDF). We investigated clinicians’ views about their use of imaging in the management of low back pain. Interviews were recorded and transcribed verbatim. We analysed transcripts, then identified themes within TDF domains. Results Most clinicians reported that, for most clinical encounters, they adhered to guideline recommendations about imaging. Many clinicians across disciplines expressed the following themes: (1) imaging may result in an incidental finding or otherwise cause harm to patients, and drive up health system costs (TDF domain Beliefs about consequences ); (2) clinicians were confident in their abilities to diagnose, to explain to patients the rationale for not recommending imaging, and to respond to their needs (domains Beliefs about capabilities; Skills) . Many clinicians identified that patients occasionally want the validation that imaging provides (domain S ocial influences). Some clinicians described the value of imaging to corroborate a diagnosis (domain Beliefs about consequences) . Conclusions This study is the first to examine influences on imaging behaviours of a large interprofessional sample of primary care clinicians in Canada. Even among knowledgeable, skilled, confident clinicians who reported mostly adhering to guideline recommendations, there are potential influences on deviating from guideline-adherent care.

Background Evidence-based guidelines for low back pain recommend against routine imaging. Despite these guidelines, many patients still seek imaging. We sought to understand why patients with low back pain may want imaging, using a qualitative approach grounded in the Common-Sense Self-Regulation Model (CSSRM), a model that frames how patients’ beliefs and actions are shaped by their past experiences and understanding of an illness. Methods We interviewed 28 patients from a larger study in Ontario, Canada. Participants were recruited by family physicians (n = 8), chiropractors (n = 10), and physiotherapists (n = 10), and most (82.1%) had previous episodes of low back pain. Participants completed intake questionnaires and semi-structured interviews that explored their experiences with low back pain care and perspectives on imaging. We analyzed the interview transcripts using the CSSRM. Results The CSSRM domains were represented in patients’ narratives: Stimuli and Illness Representations , Coping Procedures , and Appraisal of Outcomes . Within Stimuli and Representations , patients described perceptions of the causes of their pain, and they associated obtaining an image with gaining a sense of control over their diagnosis. Within Coping Procedures , Cognitive Reappraisal emerged as the construct with the most discourse, reflecting how patients interpreted and reassessed their low back pain over time. Many patients expressed the belief that imaging would resolve uncertainty, validate their experience, and confirm that nothing serious had been overlooked. Patients emphasized that imaging would “show what’s going on,” or help them “feel taken seriously”. Within Appraisal of Outcomes , patients described the self-limiting nature of their LBP; the limited discourse about emotional outcomes was often linked to frustrations and fears. The beliefs expressed in interviews were not consistent with participants’ questionnaire answers from months previously, suggesting that beliefs may shift over time. Conclusions Many patients believed imaging for low back pain was important to gain certainty in diagnosis and reassurance that treatment was appropriate. However, their beliefs about the value of imaging may not be stable over time, as they are influenced by ongoing experiences and reappraisals. To reduce unwarranted imaging, clinicians should consider providing consistent and contextualized messaging that meets the patient’s ongoing illness experience.

Background At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings. Methods The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients. Discussion This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

The former South West Local Health Integration Network (SW LHIN) of Ontario, which is in a predominantly rural region, regularly reports the lowest rates of caregiver distress in the province. Caregivers from rural communities regularly face challenges related to the access, applicability, and availability of supports and services, This qualitative case study describes perspectives of caregiving from the region, and explores how role construction and expectations of caregivers might both mitigate distress and influence service support use. Thematic analysis identified five themes: anticipated care, gendered caring, service support assumptions, confidence in community, and the “line in the sand”: care decisions for evolving needs. Using the lens of caregiver identity theory, the findings suggest that these caregivers conceptualize identity as an extension of their primary role, to include caregiving obligations and responsibilities. We also noted a steadfast confidence in community and perceived service support assumptions across the region, with no notable rural–urban divide. L’ancien Réseau local d’intégration des services de santé (RLISS) du Sud-Ouest de l’Ontario, une région essentiellement rurale, affiche régulièrement les taux les plus bas de détresse des aidants dans la province. Les aidants des communautés rurales sont régulièrement confrontés à des défis liés à l’accessibilité, la mise en œuvre et la disponibilité du soutien et des services. Cette étude de cas qualitative décrit les points de vue des aidants de la région et explore comment la conception de leur rôle et leurs attentes peuvent à la fois atténuer leur détresse et influencer leur utilisation des services de soutien. L’analyse thématique a permis de dégager cinq thèmes : l’accompagnement anticipé, la prise en charge genrée, les hypothèses sur le soutien des services, la confiance en la communauté et la définition de limites dans les décisions relatives à l’aidance quand les besoins évoluent. À travers le prisme de la théorie de l’identité de l’aidant, les résultats suggèrent que ces personnes conçoivent cette identité comme un élargissement de leur rôle principal pour inclure des obligations et responsabilités d’aidance. Nous avons également constaté une confiance inébranlable en la communauté et des perceptions de soutien des services dans l’ensemble de la région, et ce sans écart notable entre les régions rurales et les régions urbaines.

Background Stroke can affect our ability to perform daily activities, although it can be difficult to identify the underlying functional impairment(s). Recent theories highlight the importance of sensory feedback in selecting future motor actions. This selection process can involve multiple processes to achieve a behavioural goal, including selective attention, feature/object recognition, and movement inhibition. These functions are often impaired after stroke, but existing clinical measures tend to explore these processes in isolation and without time constraints. We sought to characterize patterns of post-stroke impairments in a dynamic situation where individuals must identify and select spatial targets rapidly in a motor task engaging both arms. Impairments in generating rapid motor decisions and actions could guide functional rehabilitation targets, and identify potential of individuals to perform daily activities such as driving. Methods Subjects were assessed in a robotic exoskeleton. Subjects used virtual paddles attached to their hands to hit away 200 virtual target objects falling towards them while avoiding 100 virtual distractors. The inclusion of distractor objects required subjects to rapidly assess objects located across the workspace and make motor decisions about which objects to hit. Results As many as 78 % of the 157 subjects with subacute stroke had impairments in individual global, spatial, temporal, or hand-specific task parameters relative to the 95 % performance bounds for 309 non-disabled control subjects. Subjects with stroke and neglect (Behavioural Inattention Test score <130; n = 28) were more often impaired in task parameters than other subjects with stroke. Approximately half of subjects with stroke hit proportionally more distractor objects than 95 % of controls, suggesting they had difficulty in attending to and selecting appropriate objects. This impairment was observed for affected and unaffected limbs including some whose motor performance was comparable to controls. The proportion of distractors hit also significantly correlated with the Montreal Cognitive Assessment scores for subjects with stroke ( r s  < = − 0.48, P  < 10 −9 ). Conclusions A simple robot-based task identified that many subjects with stroke have impairments in the rapid selection and generation of motor responses to task specific spatial goals in the workspace.

Objective: To evaluate the effects of auditory and visual cues on gait initiation in people with Parkinson's disease. Subjects: Fourteen subjects with Parkinson's disease were recruited from community support groups, seven of whom reported having experienced freezing when walking. Design and setting: This study was a repeated measures analysis of gait initiation performance during a single visit to a university-based motion laboratory. Following baseline trials, auditory and visual cue conditions were presented in random order. The auditory cues were rhythmic sounds with an interval matching the subject's average step time. The visual cues were high-contrast transverse lines on the floor adjusted for the subject's first step length and overall height. Main measures: Kinematic recordings enabled calculation of the timing and length of steps as well as overall velocity. The timing and magnitude of weight shift and push-off force were obtained from a force platform. Results: The magnitudes of first and second step lengths, of push-off force and of overall gait velocity were significantly greater in the visual cue condition than in the baseline condition, whereas there was no significant effect of auditory cue on these measures. Neither cue had any significant effect on the timing of key events in gait initiation. Conclusions: Transverse line visual cues enable people with Parkinson's disease to begin walking with longer steps, greater push-off force and higher velocity. Auditory cues that others have shown to improve aspects of gait in people with Parkinson's disease do not appear to have any systematic effect on the first two steps of gait initiation.

Background Stroke is known to alter muscle stretch responses following a perturbation, but little is known about the behavioural consequences of these altered feedback responses. Characterizing impairments in people with stroke in their interactions with the external environment may lead to better long term outcomes. This information can inform therapists about rehabilitation targets and help subjects with stroke avoid injury when moving in the world. Methods In this study, we developed a postural perturbation task to quantity upper limb function of subjects with subacute stroke (n = 38) and non-disabled controls (n = 74) to make rapid corrective responses with the arm. Subjects were instructed to maintain their hand at a target before and after a mechanical load was applied to the limb. Visual feedback of the hand was removed for half of the trials at perturbation onset. A number of parameters quantified subject performance, and impairment in performance was defined as outside the 95th percentile performance of control subjects. Results Individual subjects with stroke showed increased postural instability (44%), delayed motor responses (79%), delayed returns towards the spatial target (79%), and greater endpoint errors (74%). Several subjects also showed impairments in the temporal coordination of the elbow and shoulder joints when responding to the perturbation (47%). Interestingly, impairments in task parameters were often found for both arms of individual subjects with stroke (up to 58% for return time). Visual feedback did not improve performance on task parameters except for decreasing endpoint error for all subjects. Significant correlations between task performance and clinical measures were dependent on the arm assessed. Conclusions This study used a simple postural perturbation task to highlight that subjects with stroke commonly have difficulties responding to mechanical disturbances that may have important implications for their ability to perform daily activities.

Objective: To evaluate the effects of weights on postural hand tremor related to self-feeding in subjects with Parkinson's disease (PD). Design: In a repeated-measures design, postural hand tremor was recorded three times in each of three weight conditions in a single session for each subject. The order of all recording conditions was randomized. Setting: Intervention was applied and measurement was conducted in a university-based motor performance laboratory. Subjects: Fourteen men and two women diagnosed with PD and having hand tremor participated (mean age 67.1 years, mean duration of PD 4.6 years). All were community-dwelling. Intervention: The control condition consisted of holding a built-up spoon (108 g). There were two experimental conditions: holding a weighted spoon (248 g); and holding the built-up spoon while wearing a weighted wrist cuff (470 g). Main outcome measures: Three measures of tremor amplitude and two measures of tremor frequency were calculated from recordings of displacement of the spoon obtained from laser displacement sensors. Results: Repeated-measures analyses of variance revealed no signi”cant differences across conditions in any measure of tremor amplitude or in either measure of tremor frequency. Correlational and Mann–Whitney U-test analyses revealed that none of age, disease duration or medication intake had any signi”cant relationship with tremor amplitude in the control condition or with whether amplitude was altered by weights. Conclusions: The ”ndings suggest that there is no support for the clinical recommendation of using weighted utensils or weighted wrist cuffs to alleviate postural hand tremor in PD.

Logic models and case study approach to programme evaluation have proven effective in evaluating educational programmes. However, there is no article that has described a step by step process of how a logic model can inform the choice of a case study methodology. In this article, we used the clinical components of a bridging programme in Canada to illustrate the step by step process of logic model to case study methodology. We provided a background to the bridging programme, steps for designing programme evaluation logic model, and subsequently described how programme evaluation would inform the choice of case study methodology. We further described case study methodology ranging from stating the evaluation questions, epistemological position, study proposition and unit of selection, sampling techniques/types, data collection and analysis. In closing, we provided highlights of how to link the evaluation process back to the logic model developed.