The effects of digital health interventions for pulmonary rehabilitation in people with COPD: a systematic review of randomized controlled trials

Background and Objectives: Chronic Obstructive Pulmonary Disease (COPD) is the third most common cause of death globally. Pulmonary rehabilitation (PR) programmes are important to reduce COPD symptoms and improve the quality of life of people with COPD. Digital health interventions have recently been adopted in PR programmes, which allow people with COPD to participate in such programmes with low barriers. The aim of this study is to review and discuss the reported effects of digital health interventions on PR outcomes in people with COPD. Materials and Methods: To achieve the study goals, a systematic literature search was conducted using PubMed (MEDLINE), CINAHL, AMED, SPORTDiscus and the Physiotherapy Evidence Database. Randomised clinical trials (RCTs) were included if they met specified criteria. Two reviewers independently checked titles, abstracts, and performed full-text screening and data extraction. The quality assessment and risk of bias were performed in accordance with the PEDRO scale and Cochrane Risk of Bias tool 2, respectively. Results: Thirteen RCTs were included in this systematic review with 1525 participants with COPD. This systematic review showed the potential positive effect of digital health PR on the exercise capacity—measured by 6- and 12-min walking tests, pulmonary function, dyspnoea and health-related quality of life. There was no evidence for advantages of digital health PR in the improvement of anxiety, depression, and self-efficacy. Conclusions: Digital health PR is more effective than traditional PR in improving the pulmonary and physical outcomes for people with COPD, but there was no difference between the two PR programmes in improving the psychosocial outcomes. The certainty of the findings of this review is affected by the small number of included studies

Developing theory-informed knowledge translation strategies to facilitate the use of patient-reported outcome measures in interdisciplinary low back pain clinical practices in Quebec: mixed methods study

There is a growing interest among healthcare providers (HCPs) to use Patient Reported Outcome Measures (PROMs) in clinical care. PROMs can help improve patient-care provider communication and may be used to inform the need for interdisciplinary care for Low Back Pain (LBP). However, PROM implementation to support clinical decision-making is complex and requires knowledge translation (KT) interventions that will overcome barriers to using PROMs in interdisciplinary clinical settings

Identifying key domains of health-related quality of life for patients with Chronic Obstructive Pulmonary Disease: the patient perspective

Background Numerous instruments are available to measure health-related quality of life (HRQoL) in patients with Chronic Obstructive Pulmonary Disease (COPD), covering a wide array of domains ranging from symptoms such as dyspnea, cough and wheezing, to social and emotional functioning. Currently no information or guide is available yet to aid the selection of domains for a particular study or disease population. The aim of this paper is to identify which domains of HRQoL are most important with respect to COPD, from the patient perspective. Methods Twenty-one Dutch patients with COPD were asked to describe important domains impacted by COPD freely; second, they were presented with cues (domains from the Patient-Reported Outcomes Measurement Information System (PROMIS) framework) and were asked to select the domains that were most relevant to them. During the interview, the patients were asked to indicate in which way the selected domains impact their lives. Both the answers to the open question, and the patient statements motivating nomination of PROMIS domains were coded into themes. Results The most relevant (sub)domains of HRQoL for patients with COPD were: physical health (fatigue, physical functioning), social health (instrumental support, ability to participate in social roles and activities, companionship, and emotional support), and coping with COPD. Conclusion We identified which domains of HRQoL are most important to patients with COPD. One of these (coping with COPD) is not explicitly covered by PROMIS, or by traditional questionnaires that are used to measure HRQoL in COPD

Optimizing primary healthcare professional practices in chronic low back pain management

Low back pain (LBP) is a common condition worldwide. LBP is a long-term condition that has major impacts on individuals' physical, mental, and social health. To improve outcomes for individuals with LBP, interventions to improve interdisciplinary care and a more reliable and appropriate patient assessment tool are needed. The overall objective of this thesis is to optimize primary healthcare professional practices in chronic LBP management by using evidence-based practice. Different elements of outcome evaluation and interdisciplinary team practices were targeted in this thesis to achieve the overall objective. Manuscripts 1 and 2 identified the barriers to deliver self-management support and to use patient reported outcome measures (PROMs) in clinical practice among clinicians working in interdisciplinary LBP programs. A four-step methodology and the theoretical domain framework (TDF) were used to guide the development of a knowledge translation intervention using behavioral change techniques that will address the barriers and leverage the facilitators of implementing self-management support and PROMs in clinical practice. The results revealed that lack of skills, lack of time, and social influence were the main factors that restricted the delivery of self-management support in clinics. The results also revealed that lack of skills, lack of professional role clarity in using PROMs, lack of a clear plan about how to use PROMs, difficulty in using PROMs for clinical decision processes, lack of beliefs about the consequences of using PROMs, lack of time, difficulty in the integration of PROMs into routine clinical practice, and patient views were the main factors that restricted the use of PROMs in clinical practice. Multi-component behavior change and knowledge translation interventions were developed, guided by behavioral change theories, to support the implementation of self-management and PROMs by clinicians. Two of the main challenges among clinicians to using PROMs in clinical practice were that the existing patients' questionnaires were long, and the clinicians felt they lacked the skills needed to score and interpret the data of these questionnaires. Therefore, Manuscripts 3, 4, and 5 of this thesis were prepared to develop a brief, reliable, and valid health-related quality of life (HRQOL) assessment tool for individuals with LBP. First, twenty-six interviews were conducted with LBP individuals to identify the most important domains of HRQOL. Six domains were perceived as important HRQOL domains by patients, which were integrated with eight important domains identified by the National Institute of Health and ICF experts, forming a total of nine important HRQOL domains. Item Response Theory (IRT) was then used to identify the optimal performing item to assess each important HRQOL domain in LBP. The results formed a set of nine bilingual items (English and French) that were tested for clarity and relevance using cognitive interviewing with 11 experts in LBP and outcome measures, and with 16 English-speaking individuals with LBP. Nine items were revised to improve the clarity of the items and their categories. The nine revised items used to measure nine HRQOL domains is ready for validation in a larger study sample. The LBP-HRQOL measure will provide clinical teams with a quick tool to screen for HRQOL domains to identify those that need to be further assessed in depth and addressed in treatment planning. The measure will also be used to monitor the changes of LBP individuals' health outcomes.La lombalgie est une condition courante dans le monde. À long terme, elle a des impacts majeurs sur la santé physique, mentale et sociale. Afin d'améliorer la santé des individus ayant une lombalgie, il serait nécessaire d'avoir des interventions visant à améliorer les soins interdisciplinaires ainsi que d'utiliser un outil plus fiable pour l'évaluation des patients. L'objectif global de cette thèse est d'optimiser, via des données probantes, la pratique des professionnels en soins de santé primaires pour la gestion des lombalgies. Différents éléments liés à l'évaluation des résultats cliniques et à la pratique de l'interdisciplinarité ont été ciblés dans cette thèse. Les manuscrits 1 et 2 ont identifiés les obstacles à fournir un soutien à l'autogestion et l'utilisation des résultats des mesures rapportées par les patients (RMRP) en pratique clinique par les cliniciens travaillant dans des programmes de lombalgie interdisciplinaires. Une méthodologie en quatre étapes ainsi que le cadre du domaine théorique ont guidé le développement d'une intervention de transfert de connaissances à l'aide des techniques de changement de comportement. Ceci permettra de surmonter les obstacles et mettre en évidence les facilitateurs liés à l'implantation du support à l'autogestion et l'utilisation des RMRP dans la pratique clinique. Les résultats ont révélés que le manque de compétences, manque de temps, et d'influence sociale ont été les principaux facteurs qui ont limité l'acheminement de l'appui de l'autogestion dans les cliniques. Ainsi, le manque de compétence, le manque de clarté du rôle du professionnel dans l'utilisation des RMRP, l'absence d'un plan clair sur la façon d'utiliser les RMRP, la difficulté d'utilisation des RMRP pour les processus de décision clinique, le manque de croyance des conséquences de l'utilisation des RMRP, le manque de temps, la difficulté de l'intégration des RMRP, et l'opinion des patients ont été les principaux facteurs qui ont limité le recours à l'utilisation des RMRP. Les interventions à composantes multiple axées sur le changement de comportement et sur le transfert des connaissances ont été développées en se basant sur des théories de changement du comportement afin d'appuyer la mise en œuvre de l'autogestion et l'utilisation des RMRP pour les cliniciens.Deux principaux défis identifiés par les cliniciens sur l'utilisation des RMRP en pratique clinique ont été que les questionnaires existants adressés aux patients étaient longs et les cliniciens croient qu'ils n'avaient pas les compétences nécessaires pour noter et interpréter les données de ces questionnaires. Par conséquent, les Manuscrits, 3, 4 et 5 élaborent un outil d'évaluation fiable et valide sur la qualité de vie liée à la santé (QVLS) pour les personnes souffrant de lombalgie. Vingt-six entrevues ont été menées auprès de personnes ayant une lombalgie afin d'identifier les domaines les plus importants de la QVLS. Six domaines ont été perçus comme importants de la QVLS par les patients, ils ont été intégrés à huit domaines importants identifiés par l'Institut National d'experts de la santé formant un total de neuf domaines importants de la QVLS. La théorie de la réponse d'item (TRI) a été utilisée pour identifier l'item optimal pour évaluer chaque domaine important de la QVLS dans la lombalgie. Neuf items bilingues (anglais et français) qui ont été testés pour la clarté et la pertinence via entrevue cognitive avec 11 experts en lombalgie et en mesure de résultats, et avec 16 anglophones ayant une lombalgie. Les neuf items révisés et utilisés pour mesurer les neuf cadres de domaines de la QVLS sont prêts à être validés dans une étude ayant un plus grand échantillon. La mesure de la lombalgie sur la QVLS offrira aux équipes cliniques un outil rapide pour dépister les domaines de la QVLS. Cette mesure servira à surveiller les changements chez les individus affectés par la lombalgie

Maximizing the effects of asthma interventions: predictors of perceived asthma control over time

Background: Asthma is a common chronic disease that causes substantial morbidity and reduced quality of life when poorly controlled. Identifying clinical and psychosocial characteristics that influence long-term asthma control can help to match asthma management programs to the individuals' needs. Objective: Study1: To estimate the extent to which symptom status, beliefs about medications, self-efficacy, emotional function, and health care utilization predict perceived asthma control perceived asthma control over a 16 months period of time among a primary care population. Study2: To estimate the extent to which symptom status, physical, mental, and social function, and healthcare utilization predict perceived asthma control over a 6 month period of time among individuals receiving care at a respiratory specialty clinic. Methods: Study 1 and 2 are secondary analysis of data from two longitudinal studies that examined health outcomes of asthma. The first study recruited the participants from primary clinics, while the second one recruited the participants from a specialty clinic at a Montreal territory hospital. Evaluations on measures of symptom status, beliefs about medications, self-efficacy, physical, mental, and social function, and healthcare utilization were evaluated over 2 time points. Path analysis models were used to estimate the predictors of perceived asthma control in both studies, which were modeled based on the Wilson & Cleary and ICF models. The first study's path model hypothesized that symptoms, self-efficacy, beliefs about medications, emotional function, physical activity, and healthcare utilization are predictors of perceived asthma control. The second study's path model hypothesized that FEV1, symptom, mental health, physical and social function, role emotional, and healthcare utilization are predictors of perceived asthma control. Results: Study1: the path model indicated asthma symptom (B= 0.35, p= 0.00) and physical activity (B= 0.24, p= 0.01) had a significant positive total effect on perceived asthma control, while emotional function (B= 0.08, p= 0.05) and self-efficacy (B= 0.07, p= 0.02) were significant predictors indirectly through physical activity. The model explained 24% of perceived asthma control. Overall, the model fit the data well (Χ2 = 15.98, df = 10, P-value = 0.1, RMSEA = 0.045, and CFI = 0.98). Study 2: the path model indicated that FEV (B= 0.12, p= 0.01), asthma symptom (B= 0.42, p= 0.001), and social function (B= 0.37, p= 0.02) had a significant positive total effect on perceived asthma control. The model explained 34% of perceived asthma control. Overall, the model fit the data well (Χ2= 39.83, df = 27, P-value = 0.053, RMSEA = 0.065, and CFI = 0.95). Conclusion: FEV1, asthma symptom, physical activity, emotional function, social function, and self-efficacy can be used to identify patients likely to have poor perceived asthma control in the future, and should be considered when planning patient management. Identifying these predictors is important to help the care team tailor interventions that will allow individuals to optimally manage their asthma, to prevent exacerbations, to prevent other respiratory-related chronic disease, and to maximise quality of life.Contexte: L'asthme entraîne une morbidité importante et réduit la qualité de vie lorsqu'elle est mal contrôlée. L'identification des caractéristiques cliniques et psychosociales qui influent sur contrôle de l'asthme à long terme peut aider à faire concorder les programmes de gestion de l'asthme aux besoins des individus. Objectif: Étude 1: Estimer la mesure dans laquelle le statut des symptômes, les croyances concernant les médicaments, l'auto-efficacité, l'émotion, et l'utilisation des soins de santé permettent de prédire le contrôle de l'asthme perçu sur une période de 16 mois dans une population des soins primaires. Étude 2: Estimer la mesure dans laquelle le statut des symptômes physiques et mentaux, les fonctions sociales, et l'utilisation des soins de santé permettent de prédire le contrôle de l'asthme perçu sur une période de 6 mois chez les personnes recevant des soins dans une clinique spécialisée en pneumologie.Méthodes: Les études 1 et 2 sont des analyses secondaires des données provenant de deux études longitudinales qui ont examiné les effets de l'asthme sur la santé. La première étude a recruté les participants de cliniques de soins primaires, tandis que la seconde a recruté les participants à partir d'une clinique spécialisée dans un hôpital à Montréal. Les évaluations sur les mesures de l'état de symptôme, les croyances concernant les médicaments, l'auto-efficacité, physique, mental, et les fonctions sociales, et l'utilisation des soins de santé ont été évaluées à 2 points dans le temps. Des modèles d'analyse de pistes causales ont été utilisés pour estimer les facteurs prédictifs de le contrôle de l'asthme perçu dans les deux études. Les modèles utilisés se basent sur les modèles Wilson & Cleary et modèles ICF. Le modèle de piste pour la première étude a émis l'hypothèse que les symptômes, les auto-efficacités, les croyances au sujet des médicaments, l'émotion, l'activité physique, et l'utilisation des soins de santé sont des facteurs prédictifs du contrôle de l'asthme perçu. Le modèle de piste pour la deuxième étude a émis l'hypothèse que le VEMS, les symptômes, la santé mentale, les fonctions physiques et sociales, le rôle émotionnel, et l'utilisation des soins de santé sont des facteurs prédictifs du contrôle de l'asthme perçu. Résultats: Étude 1: le modèle de piste causale a indiqué que les symptômes de l'asthme (B = 0,35, p = 0,00) et l'activité physique (B = 0,24, p = 0,01) ont eu un effet positif important sur la le contrôle de l'asthme perçu totale, tandis que la fonction émotive (B = 0,08, p = 0,05) et l'auto-efficacité (B = 0,07, p = 0,02) étaient des prédicteurs significatifs indirectement au moyen de l'activité physique. Le modèle explique 24% de la le contrôle de l'asthme perçu. Les statistiques d'ajustement indiquent un bon ajustement du modèle (= 15,98 Χ2, df = 10, P-value = 0,1, RMSEA = 0,045, et la FCI = 0,98). Étude 2: le modèle de piste causale a indiqué que le VEMS (B = 0,12, p = 0,01), les symptômes d'asthme (B = 0,42, p = 0,001), et la fonction sociale (B = 0,37, p = 0,02) a eu un effet positif important sur la le contrôle de l'asthme perçu totale. Le modèle explique 34% de la le contrôle de l'asthme perçu. Les statistiques d'ajustement indiquent un bon ajustement du modèle (= 39,83 Χ2, df = 27, P-value = 0,053, RMSEA = 0,065, et la FCI = 0,95). Conclusion: Le VEMS, les symptômes de l'asthme, l'activité physique, la fonction émotive, la fonction sociale, et l'auto-efficacité peuvent être utilisés pour identifier les patients susceptibles d'avoir une mauvaise le contrôle de l'asthme perçu dans l'avenir, et devrait être considéré lors de la planification de gestion des patients. L'identification de ces prédicteurs est une étape importante pour aider les équipes d'interventions à administrer des soins sur mesure afin de contrôler l'asthme et les exacerbations des patients de façon optimale, mais également de prévenir les maladies chroniques associées, et de maximiser la qualité de vie

Failure rate of single-unit restorations on posterior vital teeth: A systematic review.

STATEMENT OF PROBLEM No knowledge synthesis exists concerning when to use a direct restoration versus a complete-coverage indirect restoration in posterior vital teeth. PURPOSE The purpose of this systematic review was to identify the failure rate of conventional single-unit tooth-supported restorations in posterior permanent vital teeth as a function of remaining tooth structure. MATERIAL AND METHODS Four databases were searched electronically, and 8 selected journals were searched manually up to February 2015. Clinical studies of tooth-supported single-unit restorative treatments with a mean follow-up period of at least 3 years were selected. The outcome measured was the restorations' clinical or radiological failure. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, the Cochrane Collaboration procedures for randomized control trials, the Strengthening the Reporting of Observational Studies in Epidemiology criteria for observational studies, 2 reviewers independently applied eligibility criteria, extracted data, and assessed the quality of the evidence of the included studies using the American Association of Critical Care Nurses' system. The weighted-mean group 5-year failure rates of the restorations were reported according to the type of treatment and remaining tooth structure. A metaregression model was used to assess the correlation between the number of remaining tooth walls and the weighted-mean 5-year failure rates. RESULTS Five randomized controlled trials and 9 observational studies were included and their quality ranged from low to moderate. These studies included a total of 358 crowns, 4804 composite resins, and 303582 amalgams. Data obtained from the randomized controlled trials showed that, regardless of the amount of remaining tooth structure, amalgams presented better outcomes than composite resins. Furthermore, in teeth with fewer than 2 remaining walls, high-quality observational studies demonstrated that crowns were better than amalgams. A clear inverse correlation was found between the amount of remaining tooth structure and restoration failure. CONCLUSIONS Insufficient high-quality data are available to support one restorative treatment or material over another for the restoration of vital posterior teeth. However, the current evidence suggests that the failure rates of treatments may depend on the amount of remaining tooth structure and types of treatment

Low Back Pain Prevalence among Distance Learning Students

Background: Low back pain as a symptom affects many individuals around the globe regardless of their economic status or sociodemographic characteristics. During the 2019 COVID-19 pandemic, students found themselves obligated to sit down for long periods of time. The aim of this current study is to investigate the impact of these prolonged periods of sitting down in front of computers on developing a new episode of low back pain. Methods and Materials: This research adopted an observational cross-section study design. Students who are currently enrolled or had experienced distance learning classes in the last 6 months were eligible to participate. An online-based questionnaire was developed by the investigators through reviewing the literature with relevant objectives. McNemar’s test was used to compare certain variables between two periods before and during online distance learning. We used paired t-tests to compare pain intensity before, during, and after online learning, while a chi-square test was used to investigate correlations between factors influencing low back pain. Results: A total of 84 students participated in the study—46 (54.8%) females and 38 (45.2%) males. Before online distance learning, only 42.9% of participants reported low back pain, while only 20% had a back injury. The mean pain scores before, during, and after online distance learning were (2.85 ± 2.16, 4.79 ± 2.6, and 4.76 ± 2.7), respectively. The pain scores before online learning were significantly lower than pain scores during and after online distance learning (p < 0.05), respectively. Conclusion: The study findings suggested that low back pain prevalence increased among students during the COVID-19 pandemic. Future research should study participants’ behavior during the online learning and assess the long-run impact of distance learning among high-school and undergraduate students

Promoting the use of self-management in patients with spine pain managed by chiropractors and chiropractic interns: barriers and design of a theory-based knowledge translation intervention

Background: The literature supports the effectiveness of self-management support (SMS) to improve health outcomes of patients with chronic spine pain. However, patient engagement in SMS programs is suboptimal. The objectives of this study were to: 1) assess participation in self-care (i.e. activation) among patients with spine pain, 2) identify patients’ barriers and enablers to using SMS, and 3) map behaviour change techniques (BCTs) to key barriers to inform the design of a knowledge translation (KT) intervention aimed to increase the use of SMS. Methods: In summer 2016, we invited 250 patients with spine pain seeking care at the Canadian Memorial Chiropractic College in Ontario, Canada to complete the Patient Activation Measure (PAM) survey to assess the level of participation in self-care. We subsequently conducted individual interviews, in summer 2017, based on the Theoretical Domains Framework (TDF) in a subset of patients to identify potential challenges to using SMS. The interview guide included 20 open-ended questions and accompanying probes. Findings were deductively analysed guided by the TDF. A panel of 7 experts mapped key barriers to BCTs, designed a KT intervention, and selected the modes of delivery. Results: Two hundred and twenty-three patients completed the PAM. Approximately 24% of respondents were not actively involved in their care. Interview findings from 13 spine pain patients suggested that the potential barriers to using SMS corresponded to four TDF domains: Environmental Context and Resources; Emotion; Memory, Attention & Decision-Making; and Behavioural Regulation. The proposed theory-based KT intervention includes paper-based educational materials, webinars and videos, summarising and demonstrating the therapeutic recommendations including exercises and other lifestyle changes. In addition, the KT intervention includes Brief Action Planning, a SMS strategy based on motivational interviewing, along with a SMART plan and reminders. Conclusions: Almost one quarter of study participants were not actively engaged in their spine care. Key barriers likely to influence uptake of SMS among patients were identified and used to inform the design of a theory-based KT intervention to increase their participation level. The proposed multi-component KT intervention may be an effective strategy to optimize the quality of spine pain care and improve patients’ health-outcomes.Other UBCNon UBCReviewedFacult

Implementation of an integrated primary care prevention and management program for chronic low back pain (LBP): patient-reported outcomes and predictors of pain interference after six months

Abstract Background Integrated primary care programs for patients living with chronic pain which are accessible, interdisciplinary, and patient-centered are needed for preventing chronicity and improving outcomes. Evaluation of the implementation and impact of such programs supports further development of primary care chronic pain management. This study examined patient-reported outcomes among individuals with low back pain (LBP) receiving care in a novel interdisciplinary primary care program. Methods Patients were referred by primary care physicians in four regions of Quebec, Canada, and eligible patients received an evidence-based interdisciplinary pain management program over a six-month period. Patients were screened for risk of chronicity. Patient-reported outcome measures of pain interference and intensity, physical function, depression, and anxiety were evaluated at regular intervals over the six-month follow-up. A multilevel regression analysis was performed to evaluate the association between patient characteristics at baseline, including risk of chronicity, and change in pain outcomes. Results Four hundred and sixty-four individuals (mean age 55.4y, 63% female) completed the program. The majority (≥ 60%) experienced a clinically meaningful improvement in pain intensity and interference at six months. Patients with moderate (71%) or high risk (81%) of chronicity showed greater improvement in pain interference than those with low risk (51%). Significant predictors of improvement in pain interference included a higher risk of chronicity, younger age, female sex, and lower baseline disability. Conclusion The outcomes of this novel LBP program will inform wider implementation considerations by identifying key components for further effectiveness, sustainability, and scale-up of the program