[Show abstract][Hide abstract] ABSTRACT: Despite available evidence for optimal management of spinal pain, poor adherence to guidelines and wide variations in healthcare services persist. One of the objectives of the Canadian Chiropractic Guideline Initiative is to develop and evaluate targeted theory- and evidence-informed interventions to improve the management of non-specific neck pain by chiropractors. In order to systematically develop a knowledge translation (KT) intervention underpinned by the Theoretical Domains Framework (TDF), we explored the factors perceived to influence the use of multimodal care to manage non-specific neck pain, and mapped behaviour change techniques to key theoretical domains.
Individual telephone interviews exploring beliefs about managing neck pain were conducted with a purposive sample of 13 chiropractors. The interview guide was based upon the TDF. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using thematic content analysis. A 15-member expert panel formally met to design a KT intervention.
Nine TDF domains were identified as likely relevant. Key beliefs (and relevant domains of the TDF) included the following: influence of formal training, colleagues and patients on clinicians (Social Influences); availability of educational material (Environmental Context and Resources); and better clinical outcomes reinforcing the use of multimodal care (Reinforcement). Facilitating factors considered important included better communication (Skills); audits of patients' treatment-related outcomes (Behavioural Regulation); awareness and agreement with guidelines (Knowledge); and tailoring of multimodal care (Memory, Attention and Decision Processes). Clinicians conveyed conflicting beliefs about perceived threats to professional autonomy (Social/Professional Role and Identity) and speed of recovery from either applying or ignoring the practice recommendations (Beliefs about Consequences). The expert panel mapped behaviour change techniques to key theoretical domains and identified relevant KT strategies and modes of delivery to increase the use of multimodal care among chiropractors.
A multifaceted KT educational intervention targeting chiropractors' management of neck pain was developed. The KT intervention consisted of an online education webinar series, clinical vignettes and a video underpinned by the Brief Action Planning model. The intervention was designed to reflect key theoretical domains, behaviour change techniques and intervention components. The effectiveness of the proposed intervention remains to be tested.
[Show abstract][Hide abstract] ABSTRACT: Diagnostic coding has several potential benefits, including improving the feasibility of data collection for research and clinical audits and providing a common language to improve interdisciplinary collaboration. The primary aim of this study was to determine the views and perspectives of chiropractors about diagnostic coding and explore the use of it in a chiropractic setting. A secondary aim was to compare the diagnostic coding undertaken by chiropractors and an independent coder.
A codin exercise based on the International Classification of Primary Care version 2, PLUS extension (ICPC-2 PLUS) provided the 14 chiropractors with some experience in diagnostic coding, followed by an interview on the topic. The interviews were analysed thematically. The participating chiropractors and an independent coder applied ICPC-2 PLUS terms to the diagnoses of 10 patients. Then the level of agreement between the chiropractors and the coder was determined and Cohen's Kappa was used to determine the agreement beyond that expected by chance.
From the interviews the three emerging themes were: 1) Advantages and disadvantages of using a clinical coding system in chiropractic practice, 2) ICPC-2 PLUS terminology issues for chiropractic practice and 3) Implementation of a coding system into chiropractic practice. The participating chiropractors did not uniformly support or condemn the idea of using diagnostic coding. However there was a strong agreement that the terminology in ICPC-2 PLUS would not be applicable or desirable for all practice types. In the coding exercise the chiropractors in total coded 202 diagnoses for 135 patients. The overall percentage agreement between the chiropractors and the coder was 52% (17% expected by chance) with a Kappa score of 0.4 (95% CI 0.3-0.7). Agreement was lower for more detailed coding (percentage agreement 35%; Kappa score of 0.3 (95% CI 0.2-0.5)).
It appears that implementation of diagnostic coding would be possible in the majority of the chiropractic practices that participated in this study. However for those chiropractors who do not focus on symptoms in their approach to clinical care, it could be challenging to use the ICPC-2 PLUS coding system, since ICPC-2 PLUS is a symptom-based classification.
Chiropractic and Manual Therapies 12/2015; 23(1):8. DOI:10.1186/s12998-015-0051-1
[Show abstract][Hide abstract] ABSTRACT: Background:
Non-pharmacological interventions have been shown to have some effectiveness in adults with dizziness; however, the effectiveness of these interventions in older people is unknown.
To determine the effects of conservative non-pharmacological interventions for dizziness in older people.
Cochrane Central Register of Controlled Trials, PubMed, EMBASE, SCOPUS, CINAHL, AMED, Index to Chiropractic Literature, PsychINFO and MANTIS were searched from inception to May 2014.
Two investigators independently screened controlled trials with dizzy participants over 60 years of age. Dizziness from a specific diagnosis such as Meniere's disease and benign positional paroxysmal vertigo were excluded. Outcome measures from included studies included self-reported dizziness and postural balance.
Two investigators independently extracted data on participants, interventions, comparison group, outcome measures and results. Methodological quality of included studies was assessed with the Cochrane Handbook 12-item risk of bias, and Cochrane Back Group 5-item clinical relevance assessment.
Seven articles consisting of seven controlled trials were included. All studies utilized some form of exercise as the main intervention including vestibular rehabilitation exercises, postural balance exercises, and Tai-Chi exercise. Studies had a high risk of bias with a lack of adequate randomization and allocation concealment, reporting on co-interventions, reporting on reasons for drop-outs, and reporting on participant compliance.
Heterogeneity between the included studies on interventions and outcome measures prohibited meta-analysis. Only two studies reported a significant difference between the intervention and comparison groups on self-reported dizziness.
There is insufficient evidence to determine the effectiveness of non-pharmacological treatments for dizziness in older people. Current evidence suffers from high risk of bias and future well-designed trials are needed with adequate blinding, randomization and compliance.
[Show abstract][Hide abstract] ABSTRACT: Objectives Implementation intervention effects can only be fully realised and understood if they are faithfully delivered. However the evaluation of implementation intervention fidelity is not commonly undertaken. The IMPLEMENT intervention was designed to improve the management of low back pain by general medical practitioners. It consisted of a two-session interactive workshop, including didactic presentations and small group discussions by trained facilitators. This study aimed to evaluate the fidelity of the IMPLEMENT intervention by assessing: (1) observed facilitator adherence to planned behaviour change techniques (BCTs); (2) comparison of observed and self-reported adherence to planned BCTs and (3) variation across different facilitators and different BCTs.
Design The study compared planned and actual, and observed versus self-assessed delivery of BCTs during the IMPLEMENT workshops.
Method Workshop sessions were audiorecorded and transcribed verbatim. Observed adherence of facilitators to the planned intervention was assessed by analysing the workshop transcripts in terms of BCTs delivered. Self-reported adherence was measured using a checklist completed at the end of each workshop session and was compared with the ‘gold standard’ of observed adherence using sensitivity and specificity analyses.
Results The overall observed adherence to planned BCTs was 79%, representing moderate-to-high intervention fidelity. There was no significant difference in adherence to BCTs between the facilitators. Sensitivity of self-reported adherence was 95% (95% CI 88 to 98) and specificity was 30% (95% CI 11 to 60).
Conclusions The findings suggest that the IMPLEMENT intervention was delivered with high levels of adherence to the planned intervention protocol.
Trial registration number The IMPLEMENT trial was registered in the Australian New Zealand Clinical Trials Registry, ACTRN012606000098538 (http://www.anzctr.org.au/trial_view.aspx?ID=1162).
BMJ Open 07/2015; 5(6):e007886. DOI:10.1136/bmjopen-2015-007886 · 2.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Many risk factors exist for falls in the elderly. Dizziness is an important risk factor for such falls. Spinal pain has also been identified as a risk factor for these falls. In this overview of the literature, we examine studies, including trials, of neck manipulation for neck pain, unsteadiness and falls risk relevant to the elderly. We also examine two related, but not mutually exclusive, mechanisms through which a putative beneficial effect may be mediated. These are the effects of neck manipulation on neck pain and on non-specific dizziness. We focus on the available evidence primarily in terms of clinical data rather than laboratory-based measures of balance. We conclude that chiropractors may have a role in falls prevention strategies in the subpopulation of the elderly that suffer from mechanical neck pain or dysfunction and non-specific dizziness. However, this role remains to be rigorously studied and properly defined.
JCCA. Journal of the Canadian Chiropractic Association. Journal de l'Association chiropratique canadienne 03/2015; 59(1).
[Show abstract][Hide abstract] ABSTRACT: Objective
To establish priority key messages for patients with osteoarthritis (OA).MethodsA Delphi survey and priority pairwise ranking activity was conducted. Participants included 51 OA experts from 13 countries and 9 patients (consumers) living with hip and/or knee OA. During 3 Delphi rounds, the panel of experts and consumers rated recommendations extracted from clinical guidelines and provided additional statements they considered important. When ≥70% of panel members agreed a statement was “essential,” it was retained for the next Delphi round. The final list of essential statements was reviewed by a consumer focus group and statements were modified for clarity if required. Finally, a priority pairwise ranking activity determined the rank order of the list of essential messages.ResultsEighty-five experts and 15 consumers were invited to participate; 51 experts and 9 consumers completed round 1 of the Delphi survey, and 43 experts and 8 consumers completed the final priority ranking activity. From an original list of 114 statements, 21 statements were rated as essential. Most statements (n = 17) related to nondrug treatment approaches for OA. Study limitations included that >50% of the panel comprised of physical therapists lead to high rankings of exercise and physical activity statements and also that only English-language statements were considered.ConclusionOA experts and consumers have identified and prioritized 21 key patient messages about OA. These messages may be used to inform the content of consumer educational materials to ensure patients are educated about the most important aspects of OA and its management.
[Show abstract][Hide abstract] ABSTRACT: Background:
Persistent knee pain in people over 50 years of age is often attributable to knee osteoarthritis (OA), a common joint condition that causes physical and psychological dysfunction. Exercise and pain coping skills training (PCST) can help reduce the impact of persistent knee pain, however, access to health professionals who deliver these services can be challenging. With increasing access to the Internet, remotely delivered Internet-based treatment approaches may provide alternatives for healthcare delivery. This pragmatic randomised controlled trial will investigate whether an Internet-delivered intervention that combines PCST and physiotherapist-guided exercise (PCST + Ex) is more effective than online educational material (educational control) in people with persistent knee pain.
We will recruit 148 people over 50 years of age with self-reported persistent knee pain consistent with knee OA from the Australian community. Following completion of baseline questionnaires, participants will be randomly allocated to access a 3-month intervention of either (i) online educational material, or (ii) the same online material plus an 8-module (once per week) Internet-based PCST program and seven Internet-delivered physiotherapy sessions with a home exercise programs to be performed 3 times per week. Outcomes will be measured at baseline, 3 months and 9 months with the primary time point at 3 months. Primary outcomes are average knee pain on walking (11-point numeric rating scale) and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index subscale). Secondary outcomes include additional measures of knee pain, health-related quality-of-life, perceived global change in symptoms, and potential moderators and mediators of outcomes including self-efficacy for pain management and function, pain coping attempts and pain catastrophising. Other measures of adherence, adverse events, harms, use of health services/co-interventions, and process measures including appropriateness and satisfaction of the intervention, will be collected at 3, 6 and 9 months.
The findings will help determine the effectiveness and acceptability of Internet access to a combination of interventions that are known to be beneficial to people with persistent knee pain. This study has the potential to guide clinical practice towards innovative modes of healthcare provision.
Australian New Zealand Clinical Trials Registry reference: ACTRN12614000243617.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND
This paper extends the findings of the Cochrane systematic review of audit and feedback on professional practice to explore the estimate of effect over time and examine whether new trials have added to knowledge regarding how optimize the effectiveness of audit and feedback.
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized trials of audit and feedback compared to usual care, with objectively measured outcomes assessing compliance with intended professional practice. Two reviewers independently screened articles and abstracted variables related to the intervention, the context, and trial methodology. The median absolute risk difference in compliance with intended professional practice was determined for each study, and adjusted for baseline performance. The effect size across studies was recalculated as studies were added to the cumulative analysis. Meta-regressions were conducted for studies published up to 2002, 2006, and 2010 in which characteristics of the intervention, the recipients, and trial risk of bias were tested as predictors of effect size.
Of the 140 randomized clinical trials (RCTs) included in the Cochrane review, 98 comparisons from 62 studies met the criteria for inclusion. The cumulative analysis indicated that the effect size became stable in 2003 after 51 comparisons from 30 trials. Cumulative meta-regressions suggested new trials are contributing little further information regarding the impact of common effect modifiers. Feedback appears most effective when: delivered by a supervisor or respected colleague; presented frequently; featuring both specific goals and action-plans; aiming to decrease the targeted behavior; baseline performance is lower; and recipients are non-physicians.
There is substantial evidence that audit and feedback can effectively improve quality of care, but little evidence of progress in the field. There are opportunity costs for patients, providers, and health care systems when investigators test quality improvement interventions that do not build upon, or contribute toward, extant knowledge.
Journal of General Internal Medicine 06/2014; 29(11). DOI:10.1007/s11606-014-2913-y · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Hot flushes and night sweats (vasomotor symptoms) are common menopausal symptoms, often causing distress, sleep deprivation and reduced quality of life. Although hormone replacement therapy is an effective treatment, there are concerns about serious adverse events. Non-hormonal pharmacological therapies are less effective and can also cause adverse effects. Complementary therapies, including acupuncture, are commonly used for menopausal vasomotor symptoms. While the evidence for the effectiveness of acupuncture in treating vasomotor symptoms is inconclusive, acupuncture has a low risk of adverse effects, and two small studies suggest it may be more effective than non-insertive sham acupuncture. Our objective is to assess the efficacy of needle acupuncture in improving hot flush severity and frequency in menopausal women. Our current study design is informed by methods tested in a pilot study.
This is a stratified, parallel, randomised sham-controlled trial with equal allocation of participants to two trial groups. We are recruiting 360 menopausal women experiencing a minimum average of seven moderate hot flushes a day over a seven-day period and who meet diagnostic criteria for the Traditional Chinese Medicine diagnosis of Kidney Yin deficiency. Exclusion criteria include breast cancer, surgical menopause, and current hormone replacement therapy use. Eligible women are randomised to receive either true needle acupuncture or sham acupuncture with non-insertive (blunt) needles for ten treatments over eight weeks. Participants are blinded to treatment allocation. Interventions are provided by Chinese medicine acupuncturists who have received specific training on trial procedures. The primary outcome measure is hot flush score, assessed using the validated Hot Flush Diary. Secondary outcome measures include health-related quality of life, anxiety and depression symptoms, credibility of the sham treatment, expectancy and beliefs about acupuncture, and adverse events. Participants will be analysed in the groups in which they were randomised using an intention-to-treat analysis strategy.
Results from this trial will significantly add to the current body of evidence on the role of acupuncture for vasomotor symptoms. If found to be effective and safe, acupuncture will be a valuable additional treatment option for women who experience menopausal vasomotor symptoms.
Australian New Zealand Clinical Trials Registry ACTRN12611000393954 11/02/2009.
[Show abstract][Hide abstract] ABSTRACT: Background
Scant research has been undertaken regarding chiropractors’ skills and knowledge associated with evidence-based practice (EBP), and their perceived barriers to EBP. These issues appear to have been examined in only one small qualitative study and one small study of chiropractors holding orthopaedic diplomas. The lack of research in this area suggests that additional studies are warranted to develop a better understanding of factors that affect chiropractors’ use of research evidence in clinical practice.
We used a modified online questionnaire that captured information regarding EBP skills and knowledge, and barriers to EBP. Its adaption was informed by the use of a content validity panel. The questionnaire was disseminated through email by Australian chiropractic professional organisations and the Chiropractic Board of Australia. Logistic regression analyses were conducted to examine univariate associations between responses to items measuring knowledge and skills with items measuring: age; years since registration; reading research literature; and use of research literature in clinical decision-making.
584 respondents returned questionnaires. About half of the respondents stated they had learned the foundations of EBP (56.6%) during their undergraduate training. Slightly more than two thirds of the respondents were confident in their ability to critically review literature (69.5%) and find relevant research to answer clinical questions (72.6%). The most common factors involved with reading more research, and increased use of research literature in clinical decision-making, were confidence in critical appraisal skills and confidence in finding relevant research literature. Conclusion Educational interventions should be implemented to enhance Australian chiropractors’ fundamental EBP skills.
Complementary therapies in medicine 04/2014; DOI:10.1016/j.ctim.2014.02.007 · 1.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Dementia is a growing problem, causing substantial burden for patients, their families, and society. General practitioners (GPs) play an important role in diagnosing and managing dementia; however, there are gaps between recommended and current practice. The aim of this study was to explore GPs' reported practice in diagnosing and managing dementia and to describe, in theoretical terms, the proposed explanations for practice that was and was not consistent with evidence-based guidelines.
Semi-structured interviews were conducted with GPs in Victoria, Australia. The Theoretical Domains Framework (TDF) guided data collection and analysis. Interviews explored the factors hindering and enabling achievement of 13 recommended behaviours. Data were analysed using content and thematic analysis. This paper presents an in-depth description of the factors influencing two behaviours, assessing co-morbid depression using a validated tool, and conducting a formal cognitive assessment using a validated scale.
A total of 30 GPs were interviewed. Most GPs reported that they did not assess for co-morbid depression using a validated tool as per recommended guidance. Barriers included the belief that depression can be adequately assessed using general clinical indicators and that validated tools provide little additional information (theoretical domain of 'Beliefs about consequences'); discomfort in using validated tools ('Emotion'), possibly due to limited training and confidence ('Skills'; 'Beliefs about capabilities'); limited awareness of the need for, and forgetting to conduct, a depression assessment ('Knowledge'; 'Memory, attention and decision processes'). Most reported practising in a manner consistent with the recommendation that a formal cognitive assessment using a validated scale be undertaken. Key factors enabling this were having an awareness of the need to conduct a cognitive assessment ('Knowledge'); possessing the necessary skills and confidence ('Skills'; 'Beliefs about capabilities'); and having adequate time and resources ('Environmental context and resources').
This is the first study to our knowledge to use a theoretical approach to investigate the barriers and enablers to guideline-recommended diagnosis and management of dementia in general practice. It has identified key factors likely to explain GPs' uptake of the guidelines. The results have informed the design of an intervention aimed at supporting practice change in line with dementia guidelines, which is currently being evaluated in a cluster randomised trial.