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ContextInvestigators in palliative care rely heavily on routinely collected data, which carry risk of unobserved confounding and selection bias. ‘Natural experiments’ offer opportunities to generate credible causal treatment effect estimates from observational data.ObjectivesWe aimed first to review studies that employed ‘natural experiments’ to evaluate palliative care, and second to consider implications for expanding use of these methods.MethodsWe searched systematically seven databases to identify studies using ‘natural experiments’ to evaluate palliative care’s effect on outcomes and costs. We searched three grey literature repositories, and hand-searched journals and prior systematic reviews. We assessed reporting using the Strengthening the Reporting of Observational Studies in Epidemiology checklist and a bespoke methodological quality tool, using two reviewers at each stage. We combined results in a narrative synthesis.ResultsWe included 17 studies, which evaluated a wide range of interventions and populations. Seven studies employed a difference-in-differences design; five each used instrumental variables and interrupted time series analysis. Outcomes of interest related mostly to healthcare use. Reporting quality was variable. Most studies reported lower costs and improved outcomes associated with palliative care, but a third of utilisation and place of death evaluations found no effect.ConclusionAmong the large number of observational studies in palliative care, a small minority have employed causal mechanisms. High-volume routine data collection, the expansion of palliative care services worldwide and recent methodological advances offer potential for increased use of ‘natural experiments’. Such studies would improve the quality of the evidence base.

BackgroundDecision-making in palliative care usually involves both patients and family caregivers. However, how concordance and discordance in decision-making manifest and function between patients and family caregivers in palliative care is not well understood.ObjectivesTo identify key factors and/or processes which underpin concordance and/or discordance between patients and family caregivers with respect to their preferences for and decisions about palliative care; and ascertain how patients and family caregivers manage discordance in decision-making in palliative care.MethodsA systematic review and narrative synthesis of original studies published in full between January 2000 and June 2021 was conducted using the following databases: Embase; Medline; CINAHL; AMED; Web of Science; PsycINFO; PsycARTICLES; and Social Sciences Full Text.ResultsAfter full-text review, 39 studies were included in the synthesis. Studies focused primarily on end-of-life care and on patient and family caregiver preferences for patient care. We found that discordance between patients and family caregivers in palliative care can manifest in relational conflict and can result from a lack of awareness of and communication about each other’s preferences for care. Patients’ advancing illness and impending death together with open dialogue about future care including advance care planning can foster consensus between patients and family caregivers.ConclusionsPatients and family caregivers in palliative care can accommodate each other’s preferences for care. Further research is needed to fully understand how patients and family caregivers move towards consensus in the context of advancing illness.

To evaluate the literature on children and young people with symptomatic hypermobility using a developmental framework. A search was conducted in EMBASE, Medline, CINAHL, Web of Science and grey literature. Full text articles reporting children and young people (birth to 24 years) with a confirmed diagnosis of symptomatic hypermobility (including Hypermobility Spectrum Disorder or hypermobile Ehlers-Danlos syndrome) using internationally recognised criteria or equivalent diagnoses were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews methodology was followed. Of the 1619 studies screened, 163 were included in the scoping review. Studies were published from 1967-2021, 30% were narrative reviews and 24% were case reports, from a range of journals. Musculoskeletal and cutaneous characteristics were common in all developmental stages. Cardiovascular characteristics including autonomic dysfunction, fatigue, and gastrointestinal issues were reported more frequently by adolescents. Young adult studies were scarce and included mostly case reports. Varied diagnostic criteria and assessment methods were identified. The Beighton Score was frequently used (93%), but rarely standardised (12%) and lacked consensus regarding the cut-off point of hypermobility. This novel systematic scoping review identifies the changing phenotype of symptomatic hypermobility from childhood to adolescence, and the unique stage of young adulthood. There is a lack of guidance regarding the utilisation of standardised tools to assess hypermobility in clinical practice and research. Numerous and inconsistent diagnostic criteria and assessment methods limit the data analysis. Case control and longitudinal studies using defined, bespoke criteria and assessments are needed.

Joint hypermobility (JH) is a term used to define active or passive joint range of motion that is beyond normal range, accounting for age, sex, and ethnicity. Symptomatic hypermobility is a term that can be used when symptoms are thought to be associated with JH. Children and young people with symptomatic hypermobility complain of musculoskeletal symptoms but also may report symptoms from other domains including gastrointestinal, cardiovascular, psychological, and urogenital. Many of these symptoms are not included in formal diagnostic criteria yet may impact negatively on their quality of life. The pattern of these symptoms may change with age. To map the literature on clinical characteristics of symptomatic hypermobility in an age and developmental context, to improve our understanding and assist in the clinical assessment of children and young people with symptomatic hypermobility. This systematic scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) methodology. Studies that include children and young people from birth to 24 years with a confirmed diagnosis of symptomatic hypermobility, HSD or hEDS using internationally recognised criteria or equivalent diagnoses will be included. Data extraction and analysis will be undertaken using an iterative process. Mapping and synthesis of the data will be carried out and gaps and limitations in the literature will be acknowledged. Results will be disseminated in a peer reviewed journal. The search strategy will be made available publicly for transparency.

ObjectiveTo investigate the incidence, prevalence, risk factors and morphological presentations of low back pain (LBP) in adolescent athletes.DesignSystematic review with meta-analysis.Data sourcesMedline, Embase, CINAHL via EBSCO, Web of Science, Scopus.Eligibility criteria for selecting studiesStudies evaluating the incidence and/or prevalence of LBP in adolescent athletes across all sports.ResultsThere were 80 studies included. The pooled incidence estimate of LBP in adolescent athletes was 11% (95% CI 8% to 13%, I2=0%) for 2 years, 36.0% (95% CI 4% to 68%, I2=99.3%) for 12 months and 14% (95% CI 7% to 22%, I2=76%) for 6 months incidence estimates. The pooled prevalence estimate of LBP in adolescent athletes was 42% (95% CI 29% to 55%, I2=96.6%) for last 12 months, 46% (95% CI 41.0% to 52%, I2=56%) for last 3 months and 16% (95% CI 9% to 23%, I2=98.3%) for point prevalence. Potential risk factors were sport participation, sport volume/intensity, concurrent lower extremity pain, overweight/high body mass index, older adolescent age, female sex and family history of LBP. The most common morphology reported was spondylolysis. Methodological quality was deemed high in 73% of cross-sectional studies and in 30% of cohort studies. Common reasons for downgrading at quality assessment were use of non-validated survey instruments and imprecision or absence of LBP definition.Summary/conclusionLBP is common among adolescent athletes, although incidence and prevalence vary considerably due to differences in study methodology, definitions of LBP and data collection.PROSPERO registration numberCRD42020157206.

ObjectiveTo summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement.Data sourcesFive databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS).ResultsAmong 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments.ConclusionsWhile several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

ObjectivesWe aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes.DesignSystematic review with meta-analysis.Data sourcesLiterature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching.Eligibility criteriaStudies evaluating prevalence of LBP in adult athletes across all sports.ResultsEighty-six studies were included (30 732, range 20–5958, participants), of which 45 were of ‘high’ quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%–80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%–88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%–94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6–4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport.ConclusionLBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

ObjectivesTo assess the efficacy of exercise, orthoses and splinting on function, pain and quality of life (QoL) for the management of mid-portion and insertional Achilles tendinopathy, and to compare different types, applications and modes of delivery within each intervention category.DesignSystematic review and meta-analysis.Data sourcesMedline, CINAHL, Embase, AMED, WHO ICTRP, Web of Science, PEDro and Cochrane Library from inception to October 2017. Citation tracking of published studies and conference proceedings and contacting experts in the field.Study eligibility criteriaControlled clinical trials evaluating either exercise, orthoses or splinting for the management of Achilles tendinopathy.MethodsIndependent reviewers undertook searches, screening and risk of bias appraisal. Primary outcomes of interest were function, pain and QoL.ResultsTwenty-two studies were included (1137 participants). Moderate level evidence favoured eccentric exercise over control for improving pain and function in mid-portion tendinopathy. Moderate level evidence favoured eccentric exercise over concentric exercise for reducing pain. There was moderate level evidence of no significant difference in pain or function between eccentric exercise and heavy slow resistance exercise. There was low level evidence that eccentric exercise was not superior to stretching for pain or QoL. There was moderate level evidence that a combined exercise protocol was not superior to a lower dosage protocol for improving functional performance. There was moderate to low level evidence of a significant difference in pain (mean difference (MD) 6.3 mm, 95% CI −4.45 to 17.04, moderate) or function (MD 1.83 Victoria Institute of Sport Assessment points, 95% CI −7.47 to 11.12, low) between high-dose and low-dose eccentric training. There was high to moderate level evidence of no difference in pain (moderate) or function (high) between orthoses and control. There was low level evidence of no significant benefit in adding a night splint to an eccentric exercise programme for function, and moderate level evidence for no reduction in pain (MD −3.50, 95% CI −10.49 to 3.48). Eccentric exercise was not superior to splinting for pain (moderate evidence) or function (low level evidence).SummaryWe conditionally recommend exercise for improving pain and function in mid-portion Achilles tendinopathy. The balance of evidence did not support recommendation of one type of exercise programme over another. We conditionally recommend against the addition of a splint to an eccentric exercise protocol and we do not recommend the use of orthoses to improve pain and function in Achilles tendinopathy.

Exercise prehabilitation prior to major surgery targets a reduction in postoperative complications through improved conditioning and respiratory function. However its effectiveness in cancer surgery is unclear. The objective of this review was to determine if preoperative high-intensity interval training (HIIT) improves preoperative fitness in patients scheduled for oncologic resection, and whether postoperative complications are impacted.