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Question: Is remotely delivered physiotherapy as good or better than face-to-face physiotherapy for the management of musculoskeletal conditions?, Design: Randomised controlled, non-inferiority trial with concealed allocation, blinded assessors and intention-to-treat analysis., Participants: A total of 210 adult participants with a musculoskeletal condition who presented for outpatient physiotherapy at five public hospitals in Sydney., Intervention: One group received a remotely delivered physiotherapy program for 6 weeks that consisted of one face-to-face physiotherapy session in conjunction with weekly text messages, phone calls at 2 and 4 weeks, and an individualised home exercise program delivered through an app. The other group received usual face-to-face physiotherapy care in an outpatient setting., Outcome Measures: The primary outcome was the Patient Specific Functional Scale at 6 weeks with a pre-specified non-inferiority margin of -15 out of 100 points. Secondary outcomes included: the Patient Specific Functional Scale at 26 weeks; kinesiophobia, pain, function/disability, global impression of change and quality of life at 6 and 26 weeks; and satisfaction with service delivery at 6 weeks., Results: The mean between-group difference (95% CI) for the Patient Specific Functional Scale at 6 weeks was 2.7 out of 100 points (-3.5 to 8.8), where a positive score favoured remotely delivered physiotherapy. The lower end of the 95% CI was greater than the non-inferiority margin. Whilst non-inferiority margins were not set for the secondary outcomes, the 95% CI of the mean between-group difference ruled out clinically meaningful differences., Conclusion: Remotely delivered physiotherapy with support via phone, text and an app is as good as face-to-face physiotherapy for the management of musculoskeletal conditions., Trial Registration: ACTRN12619000065190., (Copyright © 2024 Australian Physiotherapy Association. All rights reserved.)

Question: What are the effects of diagnostic labels and advice, and interactions between labels and advice, on perceived need for shoulder surgery for rotator cuff disease?, Design: 2×2 factorial online randomised experiment., Participants: People with shoulder pain., Intervention: Participants read a scenario describing a patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery., Outcome Measures: Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work., Results: A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect -0.5 on a 0-to-10 scale, 98.3% CI -0.7 to -0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect -1.0, 98.3% CI -1.3 to -0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome., Conclusion: Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition)., Trial Registration: ACTRN12621001370897., (Copyright © 2022 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Objective: Explore physiotherapists' attitudes, views, and beliefs towards the Australian Physiotherapy Association's (APA) Choosing Wisely recommendations., Design: Qualitative interview study., Methods: We conducted semi-structured interviews with physiotherapists who were registered to practise in Australia. We purposively recruited participants with different demographics, clinical backgrounds, and years of experience to achieve diversity in views and opinions. Interviews explored barriers and facilitators to adopting the APA's Choosing Wisely recommendations, and strategies to increase adoption. Interviews were recorded, transcribed verbatim and analysed thematically., Results: We interviewed 19 participants (79.2% of 26 who expressed interest to be interviewed). Mean (SD) age of participants was 33.4 (11.6), mean (SD) years of experience was 10 (11.4), 90% were male (n = 17) and 53% worked in private practice (n = 10). Most participants were slightly (42.1%, n = 8) or at least moderately familiar (42.1%, n = 8) with the recommendations. Barriers to adopting the recommendations included 1) clinicians' beliefs, experience, and knowledge, 2) patients' clinical presentation, their beliefs, and expectations, 3) workplace demands and culture, and 4) vague and restrictive language, and lack of awareness. Facilitators to adopting the recommendations included 1) physiotherapists' beliefs and practise patterns, 2) organisational support, and 3) clear and appropriate recommendations. Suggested strategies to increase adoption of the recommendations were 1) interventions targeting clinicians, 2) amendments to the recommendations and 3) increased awareness and access to the recommendations., Conclusion: These findings will inform the development and dissemination of future Choosing Wisely recommendations, and development of strategies to replace low-value physiotherapy with high-value physiotherapy., Level of Evidence: IV., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the effects of a patient decision aid for people considering shoulder surgery., Methods: Participants with shoulder pain considering shoulder surgery (n = 425) were recruited online and randomised to (i) a decision aid outlining the benefits and harms of shoulder surgery and non-surgical options (then randomised to a side-by-side vs. top-and-bottom display of options); and (ii) general information about shoulder pain from the NHS. Outcomes included treatment intention (primary), knowledge, attitudes, informed choice, and decisional conflict. Linear and logistic regression models were used to evaluate between-groups differences in outcomes., Results: 409 participants (96%) had post-intervention data. Mean age was 41.3 years, 44.2% were female. There was no between-group difference in post-intervention treatment intention (MD -0.2, 95% CI: -3.3 to 2.8) and likelihood of intending to have shoulder surgery (OR 0.7, 95% CI: 0.3-1.5). The decision aid slightly improved knowledge (MD 4.4, 95% CI: 0.2-8.6), but not any other secondary outcomes. The display of options did not influence any outcome., Conclusions: In this online trial, a co-designed patient decision aid had no effect on treatment intention, attitudes, informed choice, and decisional conflict, but a small effect on improving knowledge., Practice Implications: Research is needed to understand reasons for the lack of anticipated effects., Trial Registration: Australia New Zealand Clinical Trials Registry (ACTRN12621000992808)., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Most people who suffer an anterior cruciate ligament (ACL) injury search for information online., Objectives: Summarise the proportion of webpages on ACL rupture management that present evidence-based information., Design: Content analysis., Methods: We examined webpage information on ACL ruptures identified through (1) Google searches using terms synonymous with 'anterior cruciate ligament rupture' and searching 'knee surgeon' linked to each Australian capital city, and (2) websites of professional associations. The primary outcome was the proportion of webpages that suggest people can return to at least some form of sport with non-surgical management. Secondary outcomes included webpage information on return to sport with ACL reconstruction (ACLR) and non-surgical management, benefits, harms, and risk of osteoarthritis related to these options, and activity modification., Results: Out of 115 webpages analysed, 48% suggested people can return to at least some form of sport with non-surgical management. Almost half of webpages suggested most people will return to some form of sport following ACLR (41%) and mentioned benefits of ACLR (43%). Fewer webpages mentioned benefits of non-surgical management (14%), approximately two in three people return to pre-injury level of sport following ACLR (4%), risk of re-injury following ACLR (23%), most people return to sport within 9 months of ACLR (27%), activity modification as a management approach (20%), and ACLR will reduce the risk of osteoarthritis (23%)., Conclusion: Most online information on ACL rupture management isn't aligned with the best available evidence. Inaccurate information could mislead patients' treatment choices and create unrealistic expectations for return to sport., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Biofeedback is used to optimise muscle activation patterns in people with neck pain., Objectives: To evaluate the safety and efficacy of electromyographic and pressure biofeedback on pain, disability and work ability in adults with neck pain., Design: Systematic review and meta-analysis., Methods: We searched key databases and trial registries to September 2020, using terms synonymous with 'neck pain' and 'biofeedback'. We included randomised controlled trials (RCTs) evaluating biofeedback (against any comparison) for adults with neck pain. Outcomes included pain, disability, work ability and adverse events. Two authors independently selected the studies, extracted data, and evaluated risk of bias. GRADE was applied to each meta-analysis. Data were pooled using random-effects models to determine the standardised mean change (SMC)., Results: We included 15 RCTs (n = 990). Moderate-quality evidence suggests biofeedback has a moderate effect on reducing short-term disability (SMC = -0.42, 95%CI: 0.59 to -0.26, nine trials, n = 627), and a small effect on reducing intermediate-term disability (SMC = -0.30, 95%CI: 0.53 to -0.06, five trials, n = 458). Biofeedback had no effect on pain or work ability in the short- and intermediate-term (low-to moderate-quality evidence). One study reported headaches in 6.7% of participants, but headache frequency was not reported by group., Limitations: There were a variety of control interventions across studies. Few studies compared biofeedback with no treatment or placebo., Conclusion: Biofeedback appears to have a small-to-moderate effect on reducing neck pain disability in the short- and intermediate-term, but no effect on pain or work ability. More trials reporting adverse events and comparing biofeedback to placebo are needed., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Question: Do program and participant characteristics influence people's willingness to undertake exercise programs to prevent recurrence of low back pain?, Design: Discrete choice experiment., Participants: Six hundred and forty-seven people with a recent history of low back pain., Data Collection: Recruitment and participation occurred online. Participants were randomised to a block of 10 choice tasks, where the characteristics of the exercise program varied systematically. The characteristics that were presented for each exercise program were mode of exercise delivery, mode of supervision, setting, duration, weekly frequency, travel time, risk of recurrence, and costs. For each choice task, participants chose between no program or an exercise program with the characteristics as presented., Data Analysis: Choices were analysed using mixed logit models. Latent class models examined preference heterogeneity and identified participant-level characteristics predictive of preferences., Results: There appeared to be an underlying preference for exercise compared with no exercise, all else being equal. Preferences for programs were significantly influenced by the characteristics of the programs. Participants were less likely to choose exercise when programs were of a longer duration (OR 0.92, 95% CI 0.89 to 0.96 per extra month), but more likely to prefer programs offering greater reduction in the risk of recurrence of low back pain (OR 3.91, 95% CI 3.20 to 4.79 per 10% reduction in risk of recurrence). Preferences for engaging in exercise programs to prevent recurrent of low back pain were influenced by the characteristics of the programs themselves. However, there was mismatch between the preferred characteristics of exercise programs and the characteristics of known effective programs., Conclusion: People who have had low back pain should be advised explicitly about which exercise programs reduce recurrence. Understanding low back pain patients' preferences can help inform the implementation of existing prevention programs and guide the design of new prevention programs., (Copyright © 2020 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Low-value care is receiving substantial attention in many fields of medicine but little-to-none in sports medicine. Common interventions for sport and exercise-related injuries include medical imaging, medication, surgery and rehabilitation, but there is emerging evidence of the inappropriate use of these interventions. This chapter aims to increase awareness of low-value care in sports medicine by answering four key clinical questions: Does my patient need imaging? When is it appropriate to prescribe opioids? Does my patient need surgery? Does it matter how rehabilitation is delivered? Increasing awareness of low-value care in sports medicine will ensure patients with sport or exercise-related injuries avoid care that provides little-to-no benefit or causes harm and receive care that is evidence based and truly necessary. There are many situations when imaging, opioids, surgery and supervised rehabilitation are entirely appropriate. However, this chapter considers contexts where use of these interventions could be considered unnecessary and potentially harmful., (Copyright © 2019 Elsevier Ltd. All rights reserved.)