Quality appraisal as a part of the systematic review: a review of current methods

Systematic reviews frequently underpin national and international practice guidelines. Different approaches to the systematic review process, in particular quality appraisal, have been advocated. This paper discusses these approaches and highlights possible limitations which might impact upon the validity of the conclusions drawn. Practical alternatives are offered upon which systematic reviews may be appraised and conducted

A randomised controlled trial comparing graded exercise treatment and usual physiotherapy for patients with non-specific neck pain (the GET UP neck pain trial).

Evidence supports exercise-based interventions for the management of neck pain, however there is little evidence of its superiority over usual physiotherapy. This study investigated the effectiveness of a group neck and upper limb exercise programme (GET) compared with usual physiotherapy (UP) for patients with non-specific neck pain. A total of 151 adult patients were randomised to either GET or UP. The primary measure was the Northwick Park Neck pain Questionnaire (NPQ) score at six weeks, six months and 12 months. Mixed modelling identified no difference in neck pain and function between patients receiving GET and those receiving UP at any follow-up time point. Both interventions resulted in modest significant and clinically important improvements on the NPQ score with a change score of around 9% between baseline and 12 months. Both GET and UP are appropriate clinical interventions for patients with non-specific neck pain, however preferences for treatment and targeted strategies to address barriers to adherence may need to be considered in order to maximise the effectiveness of these approaches

Healthcare students’ perceptions about their role, confidence and competence to deliver brief public health interventions and advice

Background Public health improvement has long been an important focus for the United Kingdom Department of Health. The Allied Health Professions (AHP) Federation has 84,000 members, such a large number of AHP professionals should play a role in public health initiatives, but it is not clear if they or the AHP students who will be the future healthcare workforce feel themselves equipped to do so. Our aim was to understand the perceptions of AHP students about their role in delivering public health advice. Methods AHP students were recruited in one teaching university from different departments. Participants were final year AHP students who had completed all clinical placements related to their course. All students were emailed an invitation to participate, and those interested were asked to contact the researchers to participate in one of several focus groups. Data were recorded, transcribed, and analysed using framework analysis by two independent researchers. Results Nineteen students were recruited and participated in four focus groups. The main themes produced by the data analysis were: understanding of public health issues, perceptions of their role in this, challenges and opportunities to develop a public health role, and preparation for a public health role. Conclusions AHP students felt that they had a role in public health advice-giving, but barriers to providing this advice included their own lack of confidence and knowledge, time, and the environment of the clinical placement. They considered that there should be more teaching on public health issues, and that these should feature in both the curriculum and on clinical placement

Conservative management of non-specific neck pain : effectiveness of treatment, predictors of treatment outcome and upper limb disability

Neck pain is a prevalent musculoskeletal problem that consumes considerable NHS resources. The socioeconomic impact for individuals, industry and society is high. However research into the management of neck pain is sparse. Reviews of the evidence revealed relatively little high quality evidence relating to the development, progression and management of non-specific neck pain. There is emerging evidence for the use of dynamic strengthening, proprioceptive and postural exercises for neck pain, although it is not known whether group exercise based on this emerging evidence is effective compared to usual physiotherapy. There is little evidence for prognostic factors for the progression of neck pain or outcome of treatment. Consequently clinicians are unable to predict which patients are likely to develop recurrent, persistent or chronic problems and have difficulty directing patients towards the most effective treatment approaches. Finally, there is anecdotal understanding that neck problems may lead to the development of upper limb disability and that upper limb disability may influence treatment outcome for patients with neck pain. Currently the relationship between neck pain and upper limb disability remains unquantified. The information gained from these reviews was utilised in the design of a randomised controlled trial to compare group based Graded Exercise Treatment and Usual Physiotherapy (GET UP) for patients with non-specific neck pain. The first aim of this thesis was to investigate the effectiveness of a graded neck and upper limb exercise programme (GET) compared with "usual physiotherapy" (UP). A randomised controlled trial of 151 patients showed that patients receiving UP and GET interventions had reduced neck pain and disability six months following intervention. Neck pain and disability scores in the UP group reduced by 7.7% at six month followup whilst those in the GET group reduced by 5.0%. For patients who completed treatment as per protocol, GET (8.8%) was as effective as UP (9.0%). The second aim was to investigate patient psychological, socio-demographic and physical variables which predicted treatment outcome. After adjusting for baseline neck pain and disability and treatment allocation, general linear modelling identified that, regardless of intervention, deprivation status significantly predicted treatment outcome at six months. In addition, baseline fear avoidance and treatment allocation interacted to predict six month outcome. Patients with high fear avoidance were predicted to have better outcome following GET. Those with low fear avoidance were predicted to have better outcome in UP. The final aim was to investigate the relationship between neck pain and upper limb disability. Pair wise analysis revealed a strong positive correlation between neck pain and disability and upper limb disability. Linear regression indicated that the severity of upper limb disability was predicted by two main baseline variables: higher NPQ scores and lower pain self efficacy scores. In conclusion GET and UP produced small but clinically meaningful reductions in neck pain and disability. Adherence to both forms of treatment, particularly GET, was a problem. For the subgroup group of patients who adhered to the treatment protocol, GET was as effective as UP, therefore the barriers to adhering with these treaments need to be better understood by clinicians and researchers alike. The GET programme appeared to be particularly beneficial for patients exhibiting high levels of fear avoidance beliefs. Therefore patients with neck pain should be assessed for the presence of fear avoidance beliefs and where appropriate directed towards active neck and upper limb rehabilitation. Patients from areas of social deprivation fared less well with physiotherapy than those from more affluent areas, regardless of intervention type. There is a need for more research into the influence of deprivation on treatment outcome. In particular there is a need to develop and evaluate innovative and targeted approaches which are suitable for such patients. Finally, clinicians should be aware that higher levels of neck pain and lower levels of pain self efficacy may provide an early indication of the presence of upper limb disability. Effective ways of managing neck related upper limb disability need further investigation since neither treatment was effective at reducing upper limb disability

Conservative management of non-specific neck pain : effectiveness of treatment, predictors of treatment outcome and upper limb disability

Neck pain is a prevalent musculoskeletal problem that consumes considerable NHS resources. The socioeconomic impact for individuals, industry and society is high. However research into the management of neck pain is sparse. Reviews of the evidence revealed relatively little high quality evidence relating to the development, progression and management of non-specific neck pain. There is emerging evidence for the use of dynamic strengthening, proprioceptive and postural exercises for neck pain, although it is not known whether group exercise based on this emerging evidence is effective compared to usual physiotherapy. There is little evidence for prognostic factors for the progression of neck pain or outcome of treatment. Consequently clinicians are unable to predict which patients are likely to develop recurrent, persistent or chronic problems and have difficulty directing patients towards the most effective treatment approaches. Finally, there is anecdotal understanding that neck problems may lead to the development of upper limb disability and that upper limb disability may influence treatment outcome for patients with neck pain. Currently the relationship between neck pain and upper limb disability remains unquantified. The information gained from these reviews was utilised in the design of a randomised controlled trial to compare group based Graded Exercise Treatment and Usual Physiotherapy (GET UP) for patients with non-specific neck pain. The first aim of this thesis was to investigate the effectiveness of a graded neck and upper limb exercise programme (GET) compared with "usual physiotherapy" (UP). A randomised controlled trial of 151 patients showed that patients receiving UP and GET interventions had reduced neck pain and disability six months following intervention. Neck pain and disability scores in the UP group reduced by 7.7% at six month followup whilst those in the GET group reduced by 5.0%. For patients who completed treatment as per protocol, GET (8.8%) was as effective as UP (9.0%). The second aim was to investigate patient psychological, socio-demographic and physical variables which predicted treatment outcome. After adjusting for baseline neck pain and disability and treatment allocation, general linear modelling identified that, regardless of intervention, deprivation status significantly predicted treatment outcome at six months. In addition, baseline fear avoidance and treatment allocation interacted to predict six month outcome. Patients with high fear avoidance were predicted to have better outcome following GET. Those with low fear avoidance were predicted to have better outcome in UP. The final aim was to investigate the relationship between neck pain and upper limb disability. Pair wise analysis revealed a strong positive correlation between neck pain and disability and upper limb disability. Linear regression indicated that the severity of upper limb disability was predicted by two main baseline variables: higher NPQ scores and lower pain self efficacy scores. In conclusion GET and UP produced small but clinically meaningful reductions in neck pain and disability. Adherence to both forms of treatment, particularly GET, was a problem. For the subgroup group of patients who adhered to the treatment protocol, GET was as effective as UP, therefore the barriers to adhering with these treaments need to be better understood by clinicians and researchers alike. The GET programme appeared to be particularly beneficial for patients exhibiting high levels of fear avoidance beliefs. Therefore patients with neck pain should be assessed for the presence of fear avoidance beliefs and where appropriate directed towards active neck and upper limb rehabilitation. Patients from areas of social deprivation fared less well with physiotherapy than those from more affluent areas, regardless of intervention type. There is a need for more research into the influence of deprivation on treatment outcome. In particular there is a need to develop and evaluate innovative and targeted approaches which are suitable for such patients. Finally, clinicians should be aware that higher levels of neck pain and lower levels of pain self efficacy may provide an early indication of the presence of upper limb disability. Effective ways of managing neck related upper limb disability need further investigation since neither treatment was effective at reducing upper limb disability.EThOS - Electronic Theses Online ServiceArthritis Research Campaign : Hull and East Yorkshire Hospitals NHS TrustGBUnited Kingdo

Risk factors for the onset of non-specific neck pain: a systematic review.

Objective: Neck pain is a common musculoskeletal disorder, but little is known about which individuals develop neck pain. This systematic review investigated factors that constitute a risk for the onset of non-specific neck pain. Design and setting: A range of electronic databases and reference sections of relevant articles were searched to identify appropriate articles. Studies investigating risk factors for the onset of non-specific neck pain in asymptomatic populations were included. All studies were prospective with at least 1 year follow-up. Main results: 14 independent cohort studies met the inclusion criteria for the review. Thirteen studies were assessed as high quality. Female gender, older age, high job demands, low social/work support, being an ex-smoker, a history of low back disorders and a history of neck disorders were linked to the development of non-specific neck pain. Conclusions: Various clinical and sociodemographic risk factors were identified that have implications for occupational health and health policy. However, there was a lack of good-quality research investigating the predictive nature of many other variables.</p

Does deprivation influence treatment outcome in physiotherapy?

Background: The relationship between deprivation status and health is well documented with less deprived populations experiencing lower rates of morbidity and mortality than those from more deprived groups. The mechanisms that link deprivation to health are multi-factorial and complex. The relationship between deprivation and health remains largely unexplored in physiotherapy management. Objectives: To systematically collate, appraise, and summarize primary studies that investigate the relationship between deprivation and treatment outcomes in physiotherapy. Methods: A systematic search of electronic databases was performed using a specified strategy. A three-phase screening process was used to identify relevant primary studies. Two independent reviewers selected the articles, rated quality, and extracted data. Meta-analysis was not performed due to diversity of conditions, interventions, and outcome measures used. Qualitative analysis was performed, and levels of evidence were generated using an established framework. Results: Three studies met the inclusion criteria; all were deemed of high quality. All three studies found that low socioeconomic status (SES) negatively influenced physiotherapy treatment outcomes. Conclusion: There is strong evidence to suggest that low SES negatively affects treatment outcomes in physiotherapy. This is in line with findings from other areas of medicine and allied health. The relationship appears to be complex and multifaceted. Key potential causal mechanisms are identified and explored with reference to existing literature. Further research is required to elucidate this complex relationship and to allow development of strategies that reduce the impact of deprivation on physiotherapy outcomes

Patients' preferences within randomised trials: systematic review and patient level meta-analysis

Objective: To systematically review fully randomised patient preference trials and to explore the impact of preferences on attrition and outcome by meta-analysis of patient level data. Data sources: Citation search using Science Citation Index and Google Scholar and search of the main electronic databases (Medline, CINAHL, Embase, and AMED) with a combination of key words. Study selection: Fully randomised patient preference trials that compared treatments for any clinical condition were included. Other types of preference trials and crossover trials were excluded. Other inclusion criteria: participants aged 16 years and over; primary, self-reported outcomes measured on a continuous numerical scale. From 167 studies identified and screened, 17 were identified as fully randomised patient preference trials. Data synthesis: Of the 17 trials identified, 11 authors provided raw data for the meta-analysis. Data collected were baseline and follow-up data for the main outcome, randomised allocation data, preference data, and demographic data. Baseline and first post-intervention follow-up data for the main outcome were standardised. To improve homogeneity, data for only the eight musculoskeletal trials (n=1594) were combined. To estimate the effects of preferences on outcomes and attrition, three groups were compared: patients who had a preference and were randomly allocated to their preferred treatment; patients who had a preference and were randomly allocated to the treatment they did not prefer; and patients who had no preference. Results: Patients who were randomised to their preferred treatment had a standardised effect size greater than that of those who were indifferent to the treatment assignment (effect size 0.162, 95% confidence interval 0.011 to 0.314; P=0.04). Participants who received their preferred treatment also did better than participants who did not receive their preferred treatment (effect size 0.152, −0.035 to 0.339), although this was not statistically significant (P=0.11). Participants allocated to their undesired treatment had outcomes that were no different from those who were indifferent. Participants who were allocated to their undesired treatment were less likely to be lost to first follow-up compared with indifferent participants (odds ratio 1.70, 1.076 to 2.693; P=0.02). No difference was found in attrition between patients allocated to their preference and those who were indifferent. Conclusions: Preferences among patients in musculoskeletal trials are associated with treatment effects. In open randomised trials, preferences should be ascertained before randomisation.</p