Musculoskeletal disorders (MSDs) are a common reason for seeking primary health care. The STarT Musculoskeletal (MSK) tool is designed to stratify patients suffering from MSDs to risk groups, based ...on prognostic factors.
The aim was to translate and cross-culturally adapt the STarT MSK tool in a Swedish primary health care context through testing of reliability and construct validity.
We included consecutive patients with MSDs seeking primary care (n = 99). The STarT MSK was translated using international recommendations. Construct validity was investigated by correlation analysis (Spearmans Rho) with the following reference instruments: the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ), the EuroQol 5-dimension (EQ-5D) and the Musculoskeletal Health Questionnaire (MSKHQ). Reliability was tested using test-retest (Intra Class Correlation, ICC
) (n = 31). Known-groups validity was calculated with a difference of 10% between risk groups based on how the participants had answered.
The STarT MSK was successfully translated into Swedish. The participants were grouped into low risk (n = 28), medium risk (n = 60) and high risk (n = 11). The construct validity showed a moderate to high correlation with the ÖMPQ (r = .61), EQ-5D (r = .59) and MSK-HQ (r = .56). All separate items except item 2 and 9 correlated according to predefined hypotheses. Test-retest demonstrated an excellent reliability for the total score (ICC
0.85) (n = 31). The STarT MSK tool was able to differentiate by 10% between the risk groups, based on how the participants had answered.
The STarT MSK has been successfully translated and adapted into Swedish and shows acceptable measurement properties regarding test-retest reliability and aspects of validity and seems to be able to discriminate between the proposed risk groups. The tool can therefore be useful in a Swedish primary health care context. A future study needs to determine the tools predictive validity and to investigate if stratification to risk groups leads to a faster recovery and to lower health care costs.
Abstract
Objective
The purpose of this study was to develop and externally validate multivariable prediction models for future pain intensity outcomes to inform targeted interventions for patients ...with neck or low back pain in primary care settings.
Methods
Model development data were obtained from a group of 679 adults with neck or low back pain who consulted a participating United Kingdom general practice. Predictors included self-report items regarding pain severity and impact from the STarT MSK Tool. Pain intensity at 2 and 6 months was modeled separately for continuous and dichotomized outcomes using linear and logistic regression, respectively. External validation of all models was conducted in a separate group of 586 patients recruited from a similar population with patients’ predictor information collected both at point of consultation and 2 to 4 weeks later using self-report questionnaires. Calibration and discrimination of the models were assessed separately using STarT MSK Tool data from both time points to assess differences in predictive performance.
Results
Pain intensity and patients reporting their condition would last a long time contributed most to predictions of future pain intensity conditional on other variables. On external validation, models were reasonably well calibrated on average when using tool measurements taken 2 to 4 weeks after consultation (calibration slope = 0.848 95% CI = 0.767 to 0.928 for 2-month pain intensity score), but performance was poor using point-of-consultation tool data (calibration slope for 2-month pain intensity score of 0.650 95% CI = 0.549 to 0.750).
Conclusion
Model predictive accuracy was good when predictors were measured 2 to 4 weeks after primary care consultation, but poor when measured at the point of consultation. Future research will explore whether additional, nonmodifiable predictors improve point-of-consultation predictive performance.
Impact
External validation demonstrated that these individualized prediction models were not sufficiently accurate to recommend their use in clinical practice. Further research is required to improve performance through inclusion of additional nonmodifiable risk factors.
Little research has been done regarding the attitudes and behaviors of physical therapists relative to the use of evidence in practice. The purposes of this study were to describe the beliefs, ...attitudes, knowledge, and behaviors of physical therapist members of the American Physical Therapy Association (APTA) as they relate to evidence-based practice (EBP) and to generate hypotheses about the relationship between these attributes and personal and practice characteristics of the respondents.
A survey of a random sample of physical therapist members of APTA resulted in a 48.8% return rate and a sample of 488 that was fairly representative of the national membership. Participants completed a questionnaire designed to determine beliefs, attitudes, knowledge, and behaviors regarding EBP, as well as demographic information about themselves and their practice settings. Responses were summarized for each item, and logistic regression analyses were used to examine relationships among variables.
Respondents agreed that the use of evidence in practice was necessary, that the literature was helpful in their practices, and that quality of patient care was better when evidence was used. Training, familiarity with and confidence in search strategies, use of databases, and critical appraisal tended to be associated with younger therapists with fewer years since they were licensed. Seventeen percent of the respondents stated they read fewer than 2 articles in a typical month, and one quarter of the respondents stated they used literature in their clinical decision making less than twice per month. The majority of the respondents had access to online information, although more had access at home than at work. According to the respondents, the primary barrier to implementing EBP was lack of time.
Physical therapists stated they had a positive attitude about EBP and were interested in learning or improving the skills necessary to implement EBP. They noted that they needed to increase the use of evidence in their daily practice.
Background. The IMPaCT Back study (IMplementation to improve Patient Care through Targeted treatment for Back pain) is a quality improvement study which aims to investigate the effects of introducing ...and supporting a subgrouping for targeted treatment system for patients with low back pain (LBP) in primary care. This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aimed at equipping clinicians to deliver it.
The subgrouping and targeted treatment system. This system differs from 'one-size fits all' usual practice as it suggests that first contact health care practitioners should systematically allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity. Patients in each subgroup (those at low, medium or high risk of chronicity) are then managed according to a targeted treatment system of increasing complexity.
The subgrouping tools. Subgrouping tools help guide clinical decision-making about treatment and onward referral. Two subgrouping tools have been used in the IMPaCT Back study, a 9-item version used by participating physiotherapists and a 6-item version used by GPs.
The targeted treatments. The targeted treatments include a minimal intervention delivered by GPs (for those patients at low risk of poor outcome) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability (for those at medium risk) and additional cognitive-behavioural approaches to help address psychological and social obstacles to recovery (for those at high risk).
The training packages. Building on previous interventions for other pilot studies and randomized trials, we have developed and delivered clinical training and support programmes for GPs and physiotherapists.
Discussion. This paper describes in detail the IMPaCT Back study's subgrouping for targeted treatment system and the training and mentoring packages aimed at equipping clinicians to deliver it, within the IMPaCT Back study.
Study registration. ISRCTN55174281.
Musculoskeletal conditions represent a considerable burden worldwide, and are predominantly managed in primary care. Evidence suggests that many musculoskeletal conditions share similar prognostic ...factors. Systematically assessing patient's prognosis and matching treatments based on prognostic subgroups (stratified care) has been shown to be both clinically effective and cost-effective. This study (Keele Aches and Pains Study) aims to refine and examine the validity of a brief questionnaire (Keele STarT MSK tool) designed to enable risk stratification of primary care patients with the five most common musculoskeletal pain presentations. We also describe the subgroups of patients, and explore the acceptability and feasibility of using the tool and how the tool is best implemented in clinical practice. The study design is mixed methods: a prospective, quantitative observational cohort study with a linked qualitative focus group and interview study. Patients who have consulted their GP or health care practitioner about a relevant musculoskeletal condition will be recruited from general practice. Participating patients will complete a baseline questionnaire (shortly after consultation), plus questionnaires 2 and 6 months later. A subsample of patients, along with participating GPs and health care practitioners, will be invited to take part in qualitative focus groups and interviews. The Keele STarT MSK tool will be refined based on face, discriminant, construct, and predictive validity at baseline and 2 months, and validated using data from 6-month follow-up. Patient and clinician perspectives about using the tool will be explored. This study will provide a validated prognostic tool (Keele STarT MSK) with established cutoff points to stratify patients with the five most common musculoskeletal presentations into low-, medium-, and high-risk subgroups. The qualitative analysis of patient and health care perspectives will inform practitioners on how to embed the tool into clinical practice using established general practice IT systems and clinician-support packages.
Aims/hypothesis
Our objective was to examine whether longer duration of breast-feeding and later introduction of complementary foods are associated with lower glucose concentrations and insulin ...resistance (IR-HOMA) in Indian children.
Methods
Breast-feeding duration (six categories from <3 to ≥18 months) and age at introduction of complementary foods (four categories from <4 to ≥6 months) were recorded at 1, 2 and 3 year follow-up of 568 children from a birth cohort in Mysore, India. At 5 and 9.5 years of age, 518 children were assessed for glucose tolerance and IR-HOMA.
Results
All the children were initially breast-fed; 90% were breast-fed for ≥6 months and 56.7% started complementary foods at or before the age of 4 months. Each category increase in breast-feeding duration was associated with lower fasting insulin concentration (
β
= −0.05 pmol/l 95% CI −0.10, −0.004;
p
= 0.03) and IR-HOMA (
β
= −0.05 95% CI −0.10, −0.001;
p
= 0.046) at 5 years, adjusted for the child’s sex, age, current BMI, socioeconomic status, parent’s education, rural/urban residence, birthweight and maternal gestational diabetes status. Longer duration of breastfeeding was associated with higher 120-min glucose concentration at 5 years (
β
= 0.08 mmol/l 95% CI 0.001, 0.15;
p
= 0.03) but lower 120-min glucose concentration at 9.5 years (
β
= −0.09 95% CI −0.16, −0.03;
p
= 0.006). Age at starting complementary foods was unrelated to the children’s glucose tolerance and IR-HOMA.
Conclusions/interpretation
Within this cohort, in which prolonged breast-feeding was the norm, there was evidence of a protective effect of longer duration of breast-feeding against glucose intolerance at 9.5 years. At 5 years longer duration of breast-feeding was associated with lower IR-HOMA.
This study was undertaken to assess whether the diagnosis of attention deficit hyperactivity disorder (ADHD) is retained from childhood into adulthood.
A search of the literature yielded nine ...prospective studies in which cohorts of children with the disorder were formed and then reexamined 4-16 years later to determine the level of retained ADHD. The resulting data were subjected to nonlinear regression analysis to ascertain the relationship with chronological age.
The data followed an exponential decline over time to a high degree of accuracy.
The rate of ADHD in a given age group appears to decline by 50% approximately every 5 years. If a prevalence of ADHD in childhood of 4% is assumed and the exponential decline extrapolated, the estimated rate of adult ADHD ranges from about 0.8% at age 20 to 0.05% at age 40.
Muscle-thin but adipose ('thin-fat') body composition of south Asian adults contributes to their high risk of type 2 diabetes. Studies in Pune, India showed that this phenotype is present at birth. ...We aimed to determine if south Indian babies have a 'thin-fat' phenotype and if this persists in childhood.
Prospective cohort study.
Holdsworth Memorial Hospital, Mysore, India.
Children (n = 663) whose mothers were recruited from the antenatal clinics.
Weight, length, head, mid-upper-arm, abdominal circumferences; triceps and subscapular skinfolds were measured at birth, one and four years, and compared with white Caucasian babies born in Southampton, UK (birth), and UK and Dutch growth standards (one and four years).
Mysore babies were lighter (2983 g vs 3472 g; -1.10 SD, CI -1.16, -1.02) and smaller in all body measurements than UK neonates (P < 0.001). The deficit was greatest for mid-upper-arm (-1.07 SD), head (-0.89 SD) and abdominal circumferences (-0.73 SD), and least for length (-0.25 SD) and subscapular skinfold thickness (-0.19 SD). Predictors of skinfold thickness were maternal body mass index (P < 0.001) and socio-economic status (P = 0.05). At four years, subscapular skinfold thickness was larger than UK (+0.18 SD, CI +0.11, +0.25; P < 0.001) and Dutch standards (+0.61 SD, CI +0.51, +0.71; P < 0.001), despite all other body measurements remaining smaller. Predictors of 4-year skinfold thickness were neonatal skinfold thickness (P = 0.001) and maternal insulin concentrations (P = 0.05).
Mysore newborns have a 'thin-fat' phenotype. This may reflect the action of genes and/or the 'maternal environment'. The phenotype persists in childhood, and may be the forerunner of a diabetogenic adult phenotype.
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