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      Improving Primary Health Care in Chronic Musculoskeletal Conditions through Digital Media: The PEOPLE Meeting

      research-article
      , B.Physiotherapy, MSc, PhD 1 , 2 , , , B.Physiotherapy, PhD 3 , , B.Physiotherapy, PhD 4 , , PhD 3 , , B.Physiotherapy, PhD 3 , PEOPLE Meeting Participants 5
      (Reviewer), (Reviewer), (Reviewer)
      JMIR Research Protocols
      JMIR Publications Inc.
      primary health care, Internet, digital media, health service delivery

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          Abstract

          Background

          Musculoskeletal (MSK) conditions are the most common cause of severe chronic pain and disability worldwide. Despite the impact of these conditions, disparity exists in accessing high quality basic care. As a result, effective treatments do not always reach people who need services. The situation is further hampered by the current models of care that target resources to a limited area of health services (eg, joint replacement surgery), rather than the entire continuum of MSK health, which includes services provided by primary care physicians and health professionals. The use of digital media offers promising solutions to improve access to services. However, our knowledge in this field is limited. To advance the use of digital media in improving MSK care, we held a research planning meeting entitled “PEOPLE: Partnership to Enable Optimal Primary Health Care by Leveraging Digital Media in Musculoskeletal Health”. This paper reports the discussion during the meeting.

          Objective

          The objective of this study was to: (1) identify research priorities relevant to using digital media in primary health care for enhancing MSK health, and (2) develop research collaboration among researchers, clinicians, and patient/consumer communities.

          Methods

          The PEOPLE meeting included 26 participants from health research, computer science/digital media, clinical communities, and patient/consumer groups. Based on consultations with each participant prior to the meeting, we chose to focus on 3 topics: (1) gaps and issues in primary health care for MSK health, (2) current application of digital media in health care, and (3) challenges to using digital media to improve MSK health in underserviced populations.

          Results

          The 2-day discussion led to emergence of 1 overarching question and 4 research priorities. A main research priority was to understand the characteristics of those who are not able to access preventive measures and treatment for early MSK diseases. Participants indicated that this information is necessary for tailoring digital media interventions. Other priorities included: (1) studying barriers and ethical issues associated with the use of digital media to optimize MSK health and self-management, (2) improving the design of digital media tools for providing “just-in-time” health information to patients and health professionals, and (3) advancing knowledge on the effectiveness of new and existing digital media interventions.

          Conclusions

          We anticipate that the results of this meeting will be a catalyst for future research projects and new cross-sector research partnerships. Our next step will be to seek feedback on the research priorities from our collaborators and other potential partners in primary health care.

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          Most cited references38

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          OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence.

          As a prelude to developing updated, evidence-based, international consensus recommendations for the management of hip and knee osteoarthritis (OA), the Osteoarthritis Research Society International (OARSI) Treatment Guidelines Committee undertook a critical appraisal of published guidelines and a systematic review (SR) of more recent evidence for relevant therapies. Sixteen experts from four medical disciplines (primary care two, rheumatology 11, orthopaedics one and evidence-based medicine two), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. Three additional experts were invited to take part in the critical appraisal of existing guidelines in languages other than English. MEDLINE, EMBASE, Science Citation Index, CINAHL, AMED, Cochrane Library, seven Guidelines Websites and Google were searched systematically to identify guidelines for the management of hip and/or knee OA. Guidelines which met the inclusion/exclusion criteria were assigned to four groups of four appraisers. The quality of the guidelines was assessed using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument and standardised percent scores (0-100%) for scope, stakeholder involvement, rigour, clarity, applicability and editorial independence, as well as overall quality, were calculated. Treatment modalities addressed and recommended by the guidelines were summarised. Agreement (%) was estimated and the best level of evidence to support each recommendation was extracted. Evidence for each treatment modality was updated from the date of the last SR in January 2002 to January 2006. The quality of evidence was evaluated using the Oxman and Guyatt, and Jadad scales for SRs and randomised controlled trials (RCTs), respectively. Where possible, effect size (ES), number needed to treat, relative risk (RR) or odds ratio and cost per quality-adjusted life year gained (QALY) were estimated. Twenty-three of 1462 guidelines or consensus statements retrieved from the literature search met the inclusion/exclusion criteria. Six were predominantly based on expert opinion, five were primarily evidence based and 12 were based on both. Overall quality scores were 28%, 41% and 51% for opinion-based, evidence-based and hybrid guidelines, respectively (P=0.001). Scores for aspects of quality varied from 18% for applicability to 67% for scope. Thirteen guidelines had been developed for specific care settings including five for primary care (e.g., Prodigy Guidance), three for rheumatology (e.g., European League against Rheumatism recommendations), three for physiotherapy (e.g., Dutch clinical practice guidelines for physical therapy) and two for orthopaedics (e.g., National Institutes of Health consensus guidelines), whereas 10 did not specify the target users (e.g., Ontario guidelines for optimal therapy). Whilst 14 guidelines did not separate hip and knee, eight were specific for knee but only one for hip. Fifty-one different treatment modalities were addressed by these guidelines, but only 20 were universally recommended. Evidence to support these modalities ranged from Ia (meta-analysis/SR of RCTs) to IV (expert opinion). The efficacy of some modalities of therapy was confirmed by the results of RCTs published between January 2002 and 2006. These included exercise (strengthening ES 0.32, 95% confidence interval (CI) 0.23, 0.42, aerobic ES 0.52, 95% CI 0.34, 0.70 and water-based ES 0.25, 95% CI 0.02, 0.47) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ES 0.32, 95% CI 0.24, 0.39). Examples of other treatment modalities where recent trials failed to confirm efficacy included ultrasound (ES 0.06, 95% CI -0.39, 0.52), massage (ES 0.10, 95% CI -0.23, 0.43) and heat/ice therapy (ES 0.69, 95% CI -0.07, 1.45). The updated evidence on adverse effects also varied from treatment to treatment. For example, while the evidence for gastrointestinal (GI) toxicity of non-selective NSAIDs (RR=5.36, 95% CI 1.79, 16.10) and for increased risk of myocardial infarction associated with rofecoxib (RR=2.24, 95% CI 1.24, 4.02) were reinforced, evidence for other potential drug related adverse events such as GI toxicity with acetaminophen or myocardial infarction with celecoxib remained inconclusive. Twenty-three guidelines have been developed for the treatment of hip and/or knee OA, based on opinion alone, research evidence or both. Twenty of 51 modalities of therapy are universally recommended by these guidelines. Although this suggests that a core set of recommendations for treatment exists, critical appraisal shows that the overall quality of existing guidelines is sub-optimal, and consensus recommendations are not always supported by the best available evidence. Guidelines of optimal quality are most likely to be achieved by combining research evidence with expert consensus and by paying due attention to issues such as editorial independence, stakeholder involvement and applicability. This review of existing guidelines provides support for the development of new guidelines cognisant of the limitations in existing guidelines. Recommendations should be revised regularly following SR of new research evidence as this becomes available.
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            Controlled physical activity trials in cancer survivors: a systematic review and meta-analysis.

            Approximately 9.8 million cancer survivors are alive in the United States today. Enthusiasm for prescribing physical activity for cancer survivors depends on evidence regarding whether physical activity during or after completion of treatment results in improved outcomes such as cardiorespiratory fitness, fatigue, symptoms, quality of life, mental health, or change in body size. A systematic qualitative and quantitative review of the English language scientific literature identified controlled trials of physical activity interventions in cancer survivors during and after treatment. Data from 32 studies were abstracted, weighted mean effect sizes (WMES) were calculated from the 22 high-quality studies, and a systematic level of evidence criteria was applied to evaluate 25 outcomes. There was qualitative and quantitative evidence of a small to moderate effect of physical activity interventions on cardiorespiratory fitness (WMES = 0.51 and 0.65 during and after treatment respectively, P < 0.01), physiologic outcomes and symptoms during treatment (WMES = 0.28, P < 0.01 and 0.39, P < 0.01, respectively), and vigor posttreatment (WMES = 0.83, P = 0.04). Physical activity was well tolerated in cancer survivors during and after treatment, but the available literature does not allow conclusions to be drawn regarding adverse events from participation. Physical activity improves cardiorespiratory fitness during and after cancer treatment, symptoms and physiologic effects during treatment, and vigor posttreatment. Additional physical activity intervention studies are needed to more firmly establish the range and magnitude of positive effects of physical activity among cancer survivors.
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              Understanding the burden of musculoskeletal conditions. The burden is huge and not reflected in national health priorities.

                Author and article information

                Contributors
                Journal
                JMIR Res Protoc
                JMIR Res Protoc
                ResProt
                JMIR Research Protocols
                JMIR Publications Inc. (Toronto, Canada )
                1929-0748
                Jan-Jun 2013
                08 March 2013
                : 2
                : 1
                : e13
                Affiliations
                [1] 1Arthritis Research Centre of Canada Richmond, BCCanada
                [2] 2Department of Physical Therapy University of British Columbia Vancouver, BCCanada
                [3] 3Toronto Western Research Institute Toronto, ONCanada
                [4] 4Department of Physical Therapy University of Alberta Edmonton, ABCanada
                [5] 5see acknowledgements for contributors
                Author notes
                Corresponding Author: Linda C Li lli@ 123456arthritisresearch.ca
                Article
                v2i1e13
                10.2196/resprot.2267
                3628154
                23612113
                c3d126fd-7115-4599-8adf-7a39275073d1
                ©Linda C Li, Cheryl Cott, C Allyson Jones, Elizabeth M Badley, Aileen M Davis, PEOPLE Meeting Participants. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 08.03.2013.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.

                History
                : 13 July 2012
                : 01 September 2012
                : 29 January 2013
                : 09 February 2013
                Categories
                Original Paper

                primary health care,internet,digital media,health service delivery

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