Sleep Deprivation and Self-Harm Associated With Excessive Gaming: A Case Report.

Excessive gaming may be associated with sleep deprivation and self-harm. One active duty member committed self-injurious behavior to avoid work-related consequences. It was discovered that the patient participated in a video-gaming binge throughout an entire 72-hour weekend liberty. The patient experienced severe sleep deprivation to the point where he overslept and failed to report to work. He injured himself and fabricated a robbery and assault to avoid disciplinary consequences. Military health care providers should consider excessive gaming in patients presenting with sleep issues, self-harm, and disciplinary problems. As the prevalence of gaming increases, the military leadership should be aware that excessive gaming can degrade force readiness.

A systematic review of the intervention characteristics, and behavior change theory and techniques used in mother-daughter interventions targeting physical activity.

Growing gender disparities in levels of physical inactivity put women and female youths at a greater risk of associated health problems. Mother-daughter interventions have been proposed as means to promote physical activity in this at-risk cohort. However, there is a lack of clarity as to if and why these types of interventions might be effective. This systematic review examined the intervention characteristics, and behavior change theory and techniques used in these interventions to promote physical activity for mothers and daughters. PubMed, EMBASE, PsycINfO, CINAHL and Cochrane Library (Wiley) databases were searched for English language studies from inception to 13th May 2020. Interventions of any design that targeted daughters and mothers' physical activity were included. Data was extracted using the Template for Intervention Description and Replication (TIDieR) checklist, and the Behavior Change Technique (BCT) Taxonomy v1. 4962 articles were screened and 11 unique studies met the inclusion criteria. The risk of bias in studies was generally high. Narrative summary highlighted that many studies used social cognitive theory as a theoretical foundation, were based in the community and less than three months in duration with multiple sessions per week. Thirty-seven behavior change techniques were identified across studies. Some techniques were deemed potentially effective including credible source, information on the health consequences of the behavior and the self-regulatory techniques of goal-setting, self-monitoring and problem-solving. Future research should consider the use of the TIDieR guidelines and BCT Taxonomy v1 to improve the quality of information for intervention development, implementation, and reporting phases.

Champions for improved adherence to guidelines in long-term care homes: a systematic review.

BACKGROUND: The champion model is increasingly being adopted to improve uptake of guideline-based care in long-term care (LTC). Studies suggest that an on-site champion may improve the quality of care residents' health outcomes. This review assessed the effectiveness of the champion on staff adherence to guidelines and subsequent resident outcomes in LTC homes. METHOD: This was a systematic review and meta-analyses of randomised controlled trials. Eligible studies included residents aged 65 or over and nursing staff in LTC homes where there was a stand-alone or multi-component intervention that used a champion to improve staff adherence to guidelines and resident outcomes. The measured outcomes included staff adherence to guidelines, resident health outcomes, quality of life, adverse events, satisfaction with care, or resource use. Study quality was assessed with the Cochrane Risk of Bias tool; evidence certainty was assessed using the GRADE approach. RESULTS: After screening 4367 citations, we identified 12 articles that included the results of 1 RCT and 11 cluster-RCTs. All included papers evaluated the effects of a champion as part of a multicomponent intervention. We found low certainty evidence that champions as part of multicomponent interventions may improve staff adherence to guidelines. Effect sizes varied in magnitude across studies including unadjusted risk differences (RD) of 4.1% [95% CI: - 3%, 9%] to 44.8% [95% CI: 32%, 61%] for improving pressure ulcer prevention in a bed and a chair, respectively, RD of 44% [95% CI: 17%, 71%] for improving depression identification and RD of 21% [95% CI: 12%, 30%] for improving function-focused care to residents. CONCLUSION: Champions may improve staff adherence to evidence-based guidelines in LTC homes. However, methodological issues and poor reporting creates uncertainty around these findings. It is premature to recommend the widespread use of champions to improve uptake of guideline-based care in LTC without further study of the champion role and its impact on cost. TRIAL REGISTRATION: PROSPERO CRD42019145579 . Registered on 20 August 2019.

Evaluating the effects of behavior change training on the knowledge, confidence and skills of sport and exercise science students.

BACKGROUND: Behavior change interventions have the potential to have a transformative effect on the health of populations. Allied health professionals have a key role to play in delivering these interventions. However, traditionally undergraduate allied health professional programs have not had a behavior change focus. The aim of this study was to assess the effectiveness of a training program on sport and exercise science students' knowledge, confidence and skills in the provision of behavior change support. METHOD: A mixed method convergent design was used to address the research question. Fifteen sport and exercise science students took part in a training program consisting of seven 90-min weekly face to face group sessions. Student satisfaction with training methods was assessed. Pre-to-post training changes in students' confidence and knowledge in the provision of behavior change support was evaluated. Delivery of behavior change support was assessed by an audio recorded role-play rated by an expert using the Health Care Climate Questionnaire, and an adapted version of the Communication Evaluation in Rehabilitation Tool. Students also completed a reflective assignment. RESULTS: Students were satisfied with the training. There were increases in students' confidence and knowledge of certain behavior change components post-training but not behavior change techniques. Students delivered behavior change support in a broadly needs supportive manner. The reflective assignment showed that students found particular behavior change strategies difficult to implement. CONCLUSION: It is feasible to train undergraduate students in particular components of behavior change support. Academic institutions should embed behavior change training into the allied health professional curriculum to ensure graduates are job ready with the knowledge, confidence and skills to support health related behavior change within the wider health system.

Feasibility cluster randomised controlled trial evaluating a theory-driven group-based complex intervention versus usual physiotherapy to support self-management of osteoarthritis and low back pain (SOLAS).

BACKGROUND: The self-management of osteoarthritis (OA) and low back pain (LBP) through activity and skills (SOLAS) theory-driven group-based complex intervention was developed primarily for the evaluation of its acceptability to patients and physiotherapists and the feasibility of trial procedures, to inform the potential for a definitive trial. METHODS: This assessor-blinded multicentre two-arm parallel cluster randomised controlled feasibility trial compared the SOLAS intervention to usual individual physiotherapy (UP; pragmatic control group). Patients with OA of the hip, knee, lumbar spine and/or chronic LBP were recruited in primary care physiotherapy clinics (i.e. clusters) in Dublin, Ireland, between September 2014 and November 2015. The primary feasibility objectives were evaluated using quantitative methods and individual telephone interviews with purposive samples of participants and physiotherapists. A range of secondary outcomes were collected at baseline, 6 weeks (behaviour change only), 2 months and 6 months to explore the preliminary effects of the intervention. Analysis was by intention-to-treat according to participants' cluster allocation and involved descriptive analysis of the quantitative data and inductive thematic analysis of the qualitative interviews. A linear mixed model was used to contrast change over time in participant secondary outcomes between treatment arms, while adjusting for study waves and clusters. RESULTS: Fourteen clusters were recruited (7 per trial arm), each cluster participated in two waves of recruitment, with the average cluster size below the target of six participants (intervention: mean (SD) = 4.92 (1.31), range 2-7; UP: mean (SD) = 5.08 (2.43), range 1-9). One hundred twenty participants (83.3% of n = 144 expected) were recruited (intervention n = 59; UP n = 61), with follow-up data obtained from 80.8% (n = 97) at 6 weeks, 84.2% (n = 101) at 2 months and 71.7% (n = 86) at 6 months. Most participants received treatment as allocated (intervention n = 49; UP n = 54). The qualitative interviews (12 participants; 10 physiotherapists (PTs) found the intervention and trial procedures acceptable and appropriate, with minimal feasible adaptations required. Linear mixed methods showed improvements in most secondary outcomes at 2 and 6 months with small between-group effects. CONCLUSIONS: While the SOLAS intervention and trial procedures were acceptable to participants and PTs, the recruitment of enough participants is the biggest obstacle to a definitive trial. TRIAL REGISTRATION: ISRCTN ISRCTN49875385 . Registered on 26 March 2014.

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.

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.

Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework.

BACKGROUND: Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP. METHODS: We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach. RESULTS: Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies). CONCLUSIONS: Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption. REGISTRATION: PROSPERO 2017, CRD42017070703.

Evaluation of an E-Learning Training Program to Support Implementation of a Group-Based, Theory-Driven, Self-Management Intervention For Osteoarthritis and Low-Back Pain: Pre-Post Study.

BACKGROUND: By adaptation of the face-to-face physiotherapist-training program previously used in the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) feasibility trial, an asynchronous, interactive, Web-based, e-learning training program (E-SOLAS) underpinned by behavior and learning theories was developed. OBJECTIVE: This study investigated the effect of the E-SOLAS training program on relevant outcomes of effective training and implementation. METHODS: Thirteen physiotherapists from across Ireland were trained via E-SOLAS by using mixed methods, and seven physiotherapists progressed to implementation of the 6-week group-based SOLAS intervention. The effectiveness of E-SOLAS was evaluated using the Kirkpatrick model at the levels of reaction (physiotherapist engagement and satisfaction with E-SOLAS training methods and content), learning (pre- to posttraining changes in physiotherapists' confidence and knowledge in delivering SOLAS content and self-determination theory-based communication strategies, administered via a SurveyMonkey questionnaire), and behavior (fidelity to delivery of SOLAS content using physiotherapist-completed weekly checklists). During implementation, five physiotherapists audio recorded delivery of one class, and the communication between physiotherapists and clients was assessed using the Health Care Climate Questionnaire (HCCQ), the Controlling Coach Behaviour Scale (CCBS), and an intervention-specific measure (ISM; 7-point Likert scale). A range of implementation outcomes were evaluated during training and delivery (ie, acceptability, appropriateness, feasibility, fidelity, and sustainability of E-SOLAS) using a posttraining feedback questionnaire and individual semistructured telephone interviews. RESULTS: With regard to their reaction, physiotherapists (n=13) were very satisfied with E-SOLAS posttraining (median 5.0; interquartile range 1.0; min-max 4.0-5.0) and completed training within 3-4 weeks. With regard to learning, there were significant increases in physiotherapists' confidence and knowledge in delivery of all SOLAS intervention components (P<.05). Physiotherapists' confidence in 7 of 10 self-determination theory-based communication strategies increased (P<.05), whereas physiotherapists' knowledge of self-determination theory-based strategies remained high posttraining (P>.05). In terms of behavior, physiotherapists delivered SOLAS in a needs supportive manner (HCCQ: median 5.2, interquartile range 1.3, min-max 3.7-5.8; CCBS: median 6.6, interquartile range 1.0, min-max 5.6-7.0; ISM: median 4.5, interquartile range 1.2, min-max 2.8-4.8). Fidelity scores were high for SOLAS content delivery (total %mean fidelity score 93.5%; SD 4.9%). The posttraining questionnaire and postdelivery qualitative interviews showed that physiotherapists found E-SOLAS acceptable, appropriate, feasible, and sustainable within primary care services to support the implementation of the SOLAS intervention. CONCLUSIONS: This study provides preliminary evidence of the effectiveness, acceptability, and feasibility of an e-learning program to train physiotherapists to deliver a group-based self-management complex intervention in primary care settings, which is equivalent to face-to-face training outcomes and would support inclusion of physiotherapists in a definitive trial of SOLAS.

Social Status-Related Differences in Motor Activity Between Wild-Type and Mutant Zebrafish.

Use of zebrafish as a model organism in biomedical research has led to the generation of many genetically modified mutant lines to investigate various aspects of developmental and cellular processes. However, the broader effects of the underlying mutations on social and motor behavior remain poorly examined. Here, we compared the dynamics of social interactions in the Tüpfel long-fin nacre mutant line, which lacks skin pigmentation, to wild-type zebrafish; and we determined whether status-dependent differences in escape and swimming behavior existed within each strain. We show that despite similarities in aggressive activity, Tüpfel long-fin nacre pairs exhibit unstable social relationships characterized by frequent reversals in social dominance compared to wild-type pairs. The lack of strong dominance relationships in Tüpfel long-fin nacre pairs correlates with weak territoriality and overlapping spatial distribution of dominants and subordinates. Conversely, wild-type dominants displayed strong territoriality that severely limited the movement of subordinates. Additionally, the sensitivity of the startle escape response was significantly higher in wild-type subordinates compared to dominants. However, status-related differences in sensitivity of escape response in Tüpfel long-fin nacre pairs were absent. Finally, we present evidence suggesting that these differences could be a consequence of a disruption of proper visual social signals. We show that in wild-type pairs dominants are more conspicuous, and that in wild-type and Tüpfel long-fin nacre pairings wild-type fish are more likely to dominate Tüpfel long-fin nacres. Our results serve as a cautionary note in research design when morphologically engineered zebrafish for color differences are utilized in the study of social behavior and central nervous system function.

What Do Patients with Chronic Spinal Pain Expect from Their Physiotherapist?

Purpose: Evidence has suggested that patients' expectations influence the clinical course when they present with low back pain (LBP). However, little empirical evidence has outlined the nature of these expectations. The aim of this study was to describe LBP patients' expectations of physiotherapy. Method: Seventy-nine adult patients who had LBP for more than 16 weeks and were referred for physiotherapy at two hospital physiotherapy departments in St. John's, Newfoundland and Labrador, were included. They filled out a questionnaire detailing their expectations of treatment. Results: Before treatment, more than 90% of patients expected a physical examination, tests or investigations, a diagnosis, reassurance and advice, and clear explanations of causation, symptom management, and benefits and risks of treatment. Approximately half hoped for a prescription or referral to a specialist, and about 60% hoped to discuss problems in their life. Conclusions: The findings of this study indicate that patients attend physiotherapy with clear expectations about what information should be provided. Most expected tests or investigations leading to diagnosis and an explanation of causation; this presents a challenge for clinicians, given the current understanding of LBP reflected in international practice guidelines. The fact that more than half of the patients wanted to discuss problems in their life points to the need for physiotherapists to consider LBP from a bio-psychosocial perspective.

Objectif : selon certaines données probantes, les attentes des patients influencent l'évolution clinique lorsqu'ils consultent pour des douleurs lombaires (DL). Cependant, peu de données empiriques exposent la nature de ces attentes. La présente étude visait à décrire les attentes des patients ayant des DL vis-à-vis de la physiothérapie. Méthodologie : au total, 79 patients adultes atteints de DL depuis plus de 16 semaines, qui avaient été dirigés vers l'un des deux départements de physiothérapie des hôpitaux de St. John's, à Terre-Neuve-et-Labrador, ont participé à l'étude. Ils ont rempli un questionnaire détaillant leurs attentes en matière de traitement. Résultats : avant le traitement, plus de 90 % des patients s'attendaient à subir un examen physique, des tests ou des investigations et à recevoir un diagnostic, des paroles rassurantes et des conseils ainsi que des explications claires sur la cause de leur douleur, la prise en charge des symptômes et les avantages ou les risques du traitement. Environ la moitié espérait recevoir une prescription ou être dirigée vers un spécialiste, et environ 60 % souhaitaient parler de leurs problèmes personnels. Conclusion : d'après les résultats de cette étude, les patients ont des attentes claires quant à l'information qu'ils devraient recevoir en physiothérapie. La majorité s'attendent à subir des tests ou des examens qui permettront de poser un diagnostic et d'expliquer la cause de leurs problèmes. Compte tenu des connaissances des DL énoncées dans les lignes de pratique internationales, c'est un défi pour les cliniciens. Puisque plus de la moitié des patients souhaitaient parler de leurs problèmes personnels, les physiothérapeutes devraient aborder les DL d'un point de vue biopsychosocial.

Exploring physiotherapists' experiences of implementing a cognitive behavioural approach for managing low back pain and identifying barriers to long-term implementation.

OBJECTIVES: Our objectives were two-fold: (i) to describe physiotherapists' experiences of implementing a cognitive behavioural approach (CBA) for managing low back pain (LBP) after completing an extensive online training course (iBeST), and (ii) to identify how iBeST could be enhanced to support long-term implementation before scale up for widespread use. DESIGN: We conducted semi-structured interviews with 11 physiotherapists from six National Health Service departments in the Midlands, Oxfordshire and Derbyshire. Questions centred on (i) using iBeST to support implementation, (ii) what barriers they encountered to implementation and (iii) what of information or resources they required to support sustained implementation. Interviews were transcribed and thematically analysed using NVivo. Themes were categorised using the Theoretical Domains Framework (TDF). Evidence-based techniques were identified using the behaviour change technique taxonomy to target relevant TDF domains. RESULTS: Three themes emerged from interviews: anxieties about using a CBA, experiences of implementing a CBA, and sustainability for future implementation of a CBA. Themes crossed multiple TDF domains and indicated concerns with knowledge, beliefs about capabilities and consequences, social and professional roles, social influences, emotion, and environmental context and resources. We identified evidence-based strategies that may support sustainable implementation of a CBA for LBP in a physiotherapy setting. CONCLUSIONS: This study highlighted potential challenges for physiotherapists in the provision of evidence-based LBP care within the current UK NHS. Using the TDF provided the foundation to develop a tailored, evidence-based, implementation intervention to support long term use of a CBA by physiotherapists managing LBP within UK NHS outpatient departments.

The feasibility of a theory-based self-regulation intervention in schools to increase older adolescents' leisure time physical activity behavior.

The purpose of this study was to test the feasibility of a theory-based self-regulation intervention to increase older adolescents' leisure time physical activity (LTPA) behavior. Forty-nine adolescents (M = 15.78 years; SD = 0.52; 31% female) from two schools agreed to participate. Participants were randomly assigned to the experimental or control arm at the school level. The experimental group (n = 24) underwent a brief self-regulation intervention for six weeks. The control group (n = 25) continued with standard classes. Intervention fidelity data was collected to assess feasibility. Outcome measures included self-reported LTPA behavior and self-regulation technique use. Intervention sessions were delivered as intended, participant attendance was high and compliance with intervention content was acceptable. The experimental group reported higher levels of LTPA behavior eight weeks post-intervention and increased use of self-regulation techniques. A brief theory-based self-regulation intervention delivered in a school-setting appears feasible and may increase LTPA behavior and self-regulation in adolescents.

A systematic review and meta-analysis of online versus alternative methods for training licensed health care professionals to deliver clinical interventions.

BACKGROUND: Online training is growing in popularity and yet its effectiveness for training licensed health professionals (HCPs) in clinical interventions is not clear. We aimed to systematically review the literature on the effectiveness of online versus alternative training methods in clinical interventions for licensed Health Care Professionals (HCPs) on outcomes of knowledge acquisition, practical skills, clinical behaviour, self-efficacy and satisfaction. METHODS: Seven databases were searched for randomised controlled trials (RCTs) from January 2000 to June 2015. Two independent reviewers rated trial quality and extracted trial data. Comparative effects were summarised as standardised mean differences (SMD) and 95% confidence intervals. Pooled effect sizes were calculated using a random-effects model for three contrasts of online versus (i) interactive workshops (ii) taught lectures and (iii) written/electronic manuals. RESULTS: We included 14 studies with a total of 1089 participants. Most trials studied medical professionals, used a workshop or lecture comparison, were of high risk of bias and had small sample sizes (range 21-183). Using the GRADE approach, we found low quality evidence that there was no difference between online training and an interactive workshop for clinical behaviour SMD 0.12 (95% CI -0.13 to 0.37). We found very low quality evidence of no difference between online methods and both a workshop and lecture for knowledge (workshop: SMD 0.04 (95% CI -0.28 to 0.36); lecture: SMD 0.22 (95% CI: -0.08, 0.51)). Lastly, compared to a manual (n = 3/14), we found very low quality evidence that online methods were superior for knowledge SMD 0.99 (95% CI 0.02 to 1.96). There were too few studies to draw any conclusions on the effects of online training for practical skills, self-efficacy, and satisfaction across all contrasts. CONCLUSIONS: It is likely that online methods may be as effective as alternative methods for training HCPs in clinical interventions for the outcomes of knowledge and clinical behaviour. However, the low quality of the evidence precludes drawing firm conclusions on the relative effectiveness of these training methods. Moreover, the confidence intervals around our effect sizes were large and could encompass important differences in effectiveness. More robust, adequately powered RCTs are needed.

Systematic Review of Costs and Effects of Self-Management Interventions for Chronic Musculoskeletal Pain: Spotlight on Analytic Perspective and Outcomes Assessment.

Background: Evidence for the cost-effectiveness of self-management interventions for chronic musculoskeletal pain (CMP) lacks consensus, which may be due to variability in the costing methods employed. Purpose: The purposes of the study were to identify how costs and effects have been assessed in economic analysis of self-management interventions for CMP and to identify the effect of the chosen analytical perspective on cost-effectiveness conclusions. Data Sources: Five databases were searched for all study designs using relevant terms. Study Selection: Two independent researchers reviewed all titles for predefined inclusion criteria: adults (≥18 years of age) with CMP, interventions with a primary aim of promoting self-management, and conducted a cost analysis. Data Extraction: Descriptive data including population, self-management intervention, analytical perspective, and costs and effects measured were collected by one reviewer and checked for accuracy by a second reviewer. Data Synthesis: Fifty-seven studies were identified: 65% (n = 37) chose the societal perspective, of which 89% (n = 33) captured health care utilization, 92% (n = 34) reported labor productivity, 65% (n = 24) included intervention delivery, and 59% (n = 22) captured patient/family costs. Types of costs varied in all studies. Eight studies conducted analyses from both health service and societal perspectives; cost-effectiveness estimates varied with perspective chosen, but in no case was the difference sufficient to change overall policy recommendations. Limitations: Chronic musculoskeletal pain conditions where self-management is recommended, but not as a primary treatment, were excluded. Gray literature was excluded. Conclusion: Substantial heterogeneity in the cost components captured in the assessment of self-management for CMP was found; this was independent of the analytic perspective used. Greater efforts to ensure complete and consistent costings are required if reliable cost-effectiveness evidence of self-management interventions is to be generated and to inform the most appropriate perspective for economic analyses in this field.

Communication Skills Training for Practitioners to Increase Patient Adherence to Home-Based Rehabilitation for Chronic Low Back Pain: Results of a Cluster Randomized Controlled Trial.

OBJECTIVE: To assess the effect of an intervention designed to enhance physiotherapists' communication skills on patients' adherence to recommendations regarding home-based rehabilitation for chronic low back pain. DESIGN: Cluster randomized controlled trial. SETTING: Publicly funded physiotherapy clinics. PARTICIPANTS: A sample (N=308) of physiotherapists (n=53) and patients with chronic low back pain (n=255; 54% female patients; mean age, 45.3y). INTERVENTIONS: Patients received publicly funded individual physiotherapy care. In the control arm, care was delivered by a physiotherapist who had completed a 1-hour workshop on evidence-based chronic low back pain management. Patients in the experimental arm received care from physiotherapists who had also completed 8 hours of communication skills training. MAIN OUTCOME MEASURES: (1) Patient-reported adherence to their physiotherapists' recommendations regarding home-based rehabilitation measured at 1, 4, 12, and 24 weeks after the initial treatment session. (2) Pain and pain-related function measured at baseline and at 4, 12, and 24 weeks. RESULTS: A linear mixed model analysis revealed that the experimental arm patients' ratings of adherence were higher than those of controls (overall mean difference, .41; 95% confidence interval, .10-.72; d=.28; P=.01). Moderation analyses revealed that men, regardless of the intervention, showed improvements in pain-related function over time. Only women in the experimental arm showed functional improvements; female controls showed little change in function over time. The Communication Style and Exercise Compliance in Physiotherapy intervention did not influence patients' pain, regardless of their sex. CONCLUSIONS: Communication skills training for physiotherapists had short-term positive effects on patient adherence. This training may provide a motivational basis for behavior change and could be a useful component in complex interventions to promote adherence. Communication skills training may also improve some clinical outcomes for women, but not for men.

Home or foster home care versus institutional long-term care for functionally dependent older people.

BACKGROUND: Changing population demographics have led to an increasing number of functionally dependent older people who require care and medical treatment. In many countries, government policy aims to shift resources into the community from institutional care settings with the expectation that this will reduce costs and improve the quality of care compared. OBJECTIVES: To assess the effects of long-term home or foster home care versus institutional care for functionally dependent older people. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, MEDLINE, Embase, CINAHL, and two trials registers to November 2015. SELECTION CRITERIA: We included randomised and non-randomised trials, controlled before-after studies and interrupted time series studies complying with the EPOC study design criteria and comparing the effects of long-term home care versus institutional care for functionally dependent older people. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed the risk of bias of each included study. We reported the results narratively, as the substantial heterogeneity across studies meant that meta-analysis was not appropriate. MAIN RESULTS: We included 10 studies involving 16,377 participants, all of which were conducted in high income countries. Included studies compared community-based care with institutional care (care homes). The sample size ranged from 98 to 11,803 (median N = 204). There was substantial heterogeneity in the healthcare context, interventions studied, and outcomes assessed. One study was a randomised trial (N = 112); other included studies used designs that had potential for bias, particularly due lack of randomisation, baseline imbalances, and non-blinded outcome assessment. Most studies did not select (or exclude) participants for any specific disease state, with the exception of one study that only included patients if they had a stroke. All studies had methodological limitations, so readers should interpret results with caution.It is uncertain whether long-term home care compared to nursing home care decreases mortality risk (2 studies, N = 314, very-low certainty evidence). Estimates ranged from a nearly three-fold increased risk of mortality in the homecare group (risk ratio (RR) 2.89, 95% confidence interval (CI) 1.57 to 5.32) to a 62% relative reduction (RR 0.38, 95% CI 0.17 to 0.61). We did not pool data due to the high degree of heterogeneity (I2 = 94%).It is uncertain whether the intervention has a beneficial effect on physical function, as the certainty of evidence is very low (5 studies, N = 1295). Two studies reported that participants who received long-term home care had improved activities of daily living compared to those in a nursing home, whereas a third study reported that all participants performed equally on physical function.It is uncertain whether long-term home care improves happiness compared to nursing home care (RR 1.97, 95% CI 1.27 to 3.04) or general satisfaction because the certainty of evidence was very low (2 studies, N = 114).The extent to which long-term home care was associated to more or fewer adverse health outcomes than nursing home care was not reported.It is uncertain whether long-term home care compared to nursing home care decreases the risk of hospital admission (very low-certainty evidence, N = 14,853). RR estimates ranged from 2.75 (95% CI 2.59 to 2.92), showing an increased risk for those receiving care at home, to 0.82 (95% CI 0.72 to 0.93), showing a slightly reduced risk for the same group. We did not pool data due to the high degree of heterogeneity (I2 = 99%). AUTHORS' CONCLUSIONS: There are insufficient high-quality published data to support any particular model of care for functionally dependent older people. Community-based care was not consistently beneficial across all the included studies; there were some data suggesting that community-based care may be associated with improved quality of life and physical function compared to institutional care. However, community alternatives to institutional care may be associated with increased risk of hospitalisation. Future studies should assess healthcare utilisation, perform economic analysis, and consider caregiver burden.

Mediating Effect of Changes in Hand Impairments on Hand Function in Patients With Rheumatoid Arthritis: Exploring the Mechanisms of an Effective Exercise Program.

OBJECTIVE: To determine whether the effect of the Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) exercise program on hand function was mediated by changes in the proposed active ingredients: strength, dexterity, and/or range of motion. METHODS: The SARAH intervention included exercises hypothesized to improve potential mediators of grip strength, pinch strength, wrist flexion, wrist extension, finger flexion, finger extension, thumb opposition, and dexterity, which would theoretically improve self-reported hand function. All variables were measured at baseline and at 4 and 12 months. Structural equation modeling was used to assess mediation on change in hand function via change in potential mediators. RESULTS: Change in grip strength partially mediated change in hand function. Grip strength mediated 19.4% (95% confidence interval 0.9%, 37.8%) of the treatment effect. CONCLUSION: Improvements in grip strength at 4 months are likely to mediate improved hand function at 12 months. The role of joint mobility exercises is less clear and is likely influenced by the choice of measurement tools for both mobility and function outcomes. More robust measurements of wrist and hand mobility for patients with rheumatoid arthritis may be necessary to determine the relationship between this variable and self-reported hand function. Using a large trial data set, we have demonstrated that techniques used to target grip strength are key active ingredients of the SARAH exercise program and mediate its effect.

Tools developed and disseminated by guideline producers to promote the uptake of their guidelines.

BACKGROUND: The uptake of clinical practice guidelines (CPGs) is inconsistent, despite their potential to improve the quality of health care and patient outcomes. Some guideline producers have addressed this problem by developing tools to encourage faster adoption of new guidelines. This review focuses on the effectiveness of tools developed and disseminated by guideline producers to improve the uptake of their CPGs. OBJECTIVES: To evaluate the effectiveness of implementation tools developed and disseminated by guideline producers, which accompany or follow the publication of a CPG, to promote uptake. A secondary objective is to determine which approaches to guideline implementation are most effective. SEARCH METHODS: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL); NHS Economic Evaluation Database, HTA Database; MEDLINE and MEDLINE In-Process and other non-indexed citations; Embase; PsycINFO; CINAHL; Dissertations and Theses, ProQuest; Index to Theses; Science Citation Index Expanded, ISI Web of Knowledge; Conference Proceedings Citation Index - Science, ISI Web of Knowledge; Health Management Information Consortium (HMIC), and NHS Evidence up to February 2016. We also searched trials registers, reference lists of included studies and relevant websites. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-RCTs, controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies evaluating the effects of guideline implementation tools developed by recognised guideline producers to improve the uptake of their own guidelines. The guideline could target any clinical area. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane 'Risk of bias' criteria. We graded our confidence in the evidence using the approach recommended by the GRADE working group. The clinical conditions targeted and the implementation tools used were too heterogenous to combine data for meta-analysis. We report the median absolute risk difference (ARD) and interquartile range (IQR) for the main outcome of adherence to guidelines. MAIN RESULTS: We included four cluster-RCTs that were conducted in the Netherlands, France, the USA and Canada. These studies evaluated the effects of tools developed by national guideline producers to implement their CPGs. The implementation tools evaluated targeted healthcare professionals; none targeted healthcare organisations or patients.One study used two short educational workshops tailored to barriers. In three studies the intervention consisted of the provision of paper-based educational materials, order forms or reminders, or both. The clinical condition, type of healthcare professional, and behaviour targeted by the CPG varied across studies.Two of the four included studies reported data on healthcare professionals' adherence to guidelines. A guideline tool developed by the producers of a guideline probably leads to increased adherence to the guidelines; median ARD (IQR) was 0.135 (0.115 and 0.159 for the two studies respectively) at an average four-week follow-up (moderate certainty evidence), which indicates a median 13.5% greater adherence to guidelines in the intervention group. Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service. AUTHORS' CONCLUSIONS: Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests. There are limited data on the relative costs of implementing these interventions.There are no studies evaluating the effectiveness of interventions targeting the organisation of care (e.g. benchmarking tools, costing templates, etc.), or for mass media interventions. We could not draw any conclusions about our second objective, the comparative effectiveness of implementation tools, due to the small number of studies, the heterogeneity between interventions, and the clinical conditions that were targeted.

Using mixed methods evaluation to assess the feasibility of online clinical training in evidence based interventions: a case study of cognitive behavioural treatment for low back pain.

BACKGROUND: Cognitive behavioural (CB) approaches are effective in the management of non-specific low back pain (LBP). We developed the CB Back Skills Training programme (BeST) and previously provided evidence of clinical and cost effectiveness in a large pragmatic trial. However, practice change is challenged by a lack of treatment guidance and training for clinicians. We aimed to explore the feasibility and acceptability of an online programme (iBeST) for providing training in a CB approach. METHODS: This mixed methods study comprised an individually randomised controlled trial of 35 physiotherapists and an interview study of 8 physiotherapists. Participants were recruited from 8 National Health Service departments in England and allocated by a computer generated randomisation list to receive iBeST (n = 16) or a face-to-face workshop (n = 19). Knowledge (of a CB approach), clinical skills (unblinded assessment of CB skills in practice), self-efficacy (reported confidence in using new skills), attitudes (towards LBP management), and satisfaction were assessed after training. Engagement with iBeST was assessed with user analytics. Interviews explored acceptability and experiences with iBeST. Data sets were analysed independently and jointly interpreted. RESULTS: Fifteen (94 %) participants in the iBeST group and 16 (84 %) participants in the workshop group provided data immediately after training. We observed similar scores on knowledge (MD (95 % CI): 0.97 (-1.33, 3.26)), and self-efficacy to deliver the majority of the programme (MD (95 % CI) 0.25 (-1.7; 0.7)). However, the workshop group showed greater reduction in biomedical attitudes to LBP management (MD (95 % CI): -7.43 (-10.97, -3.89)). Clinical skills were assessed in 5 (33 %) iBeST participants and 7 (38 %) workshop participants within 6 months of training and were similar between groups (MD (95 % CI): 0.17(-0.2; 0.54)). Interviews highlighted that while initially sceptical, participants found iBeST acceptable. A number of strategies were identified to enhance future versions of iBeST such as including more skills practice. CONCLUSIONS: Combined quantitative and qualitative data indicated that online training was an acceptable and promising method for providing training in an evidence based complex intervention. With future enhancement, the potential reach of this training method may facilitate evidence-based practice through large scale upskilling of the workforce. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82203145 (registered prospectively on 03.09.2012).