Musculoskeletal (MSK) and Sport and Exercise Medicine (SEM) in General Practice (GP): A Novel GP-based clinic

The problem-Musculoskeletal (MSK) symptoms are common within primary care but some GPs are not comfortable managing these; waiting times for hospital appointments are a major cause of patients’ complaints. Current UK healthcare policies emphasise a need for more community-based management. We aimed to pilot an innovative general practice-based clinic to improve the management of MSK and Sport and Exercise Medicine (SEM) symptoms within general practice.

The approach-This project was conducted in an inner-city practice of approximately 9,000 patients and 5 GP partners. The practice commissioned a novel monthly 4-hour clinic staffed by one GP with a specialist interest in MSK and SEM conditions. Each patient was allocated a 20-minute appointment. All primary care staff within the practice could refer any patient for whom they considered hospital referral appropriate, with no specific exclusion criteria. Management plans included injection therapy, exercise prescription and onward referral. After three months (August-October 2014) numbers of consultations, sources of referral, reasons for referral and management outcomes were described; patient satisfaction was assessed by questionnaire, offered to 10 randomly selected patients by reception staff and self-completed by patients. Costs of the clinic were compared to current options.

Findings- All patients (14 males; 21 females; aged 35-77 years), were seen within four weeks of referral (one third of orthopaedic referrals in 2013 waited over 9 weeks for appointment). Most were referred from other GPs; some came from physiotherapy and podiatry. Shoulder problems were the most frequent reason for referral. The commonest management option was steroid injection, with most patients being given advice regarding exercise and analgesia; there were 3 onward referrals (2 physiotherapy; 1 rheumatology).

Comparing August-October data in 2014 and 2013, total, orthopaedic and rheumatology referrals were reduced by 147, 2 and 3, respectively; within the practice MSK presentations and physiotherapy and x-ray referrals were 60, 47 and 90 fewer, respectively.

The cost per attendance at the clinic was £61; initial orthopaedic-ICAT assessments cost £82 and a consultant appointment £213.

Satisfaction questionnaires were returned by all 10 selected participants and provided positive feedback, expressing preference for community-based, rather than hospital, management.

Consequence- Our pilot study indicates that this novel service model has potential for efficient and effective management of MSK and SEM complaints in primary care, reducing the need for hospital referral and the clinical burden on general practices. The innovation deserves further evaluation in a full-scale trial to determine its generalisability to other practice settings and populations.

Speaking Out Online:The Benefits and Risks of Speaking About Sexual Violence for Young People

Speaking out about sexual violence has been a fundamental part of feminist politics since the 1970s. The practice of narrating experiences of violence, either publicly or to friends and family aims to combat the culture of silence and stigmatisation that surrounds sexual violence while also helping individuals to gain a sense of empowerment and connect with other survivors. However, speaking out also contains inherent risks, especially for young people. Survivors may meet with stigmatising or disbelieving responses, and they may lose control over who knows their story and the way in which it is told and retold.
These risks and benefits are altered, and potentially exacerbated, in an online environment. While social media may increase survivors’ ability to contact and connect with others with similar experiences it also makes it harder to control when and how their story is shared. The disjuncture between online and offline environments may also increase feelings of stigmatisation and isolation.
There is a need to explore the specific risks and benefits of speaking out online given both young people’s extensive use of social media for social interactions and the increasing tendency for support and educational services targeted at young people to make use of social media and online environments. This paper draws on literature and some preliminary research to consider both risks and benefits of speaking out online and to open a conversation about the creation of supportive spaces and mechanisms for young people to speak about sexual violence in online environments.

Taking risks with translational research

The recent bankruptcy filing by deCODE, a company with an exceptional pedigree in associating genetic variance with disease onset, highlights the commercial risks of translational research. Indeed, deCODE's approach was similar to that adapted by academic researchers who seek to connect genetics and disease. We argue here that neither a purely corporate nor purely academic model is entirely appropriate for such research. Instead, we suggest that the private sector undertake the high-throughput elements of translational research, while the public sector and governments assume the role of providing long-term funding to develop gifted scientists with the confidence to attempt to use genetic data as a stepping stone to a truly mechanistic understanding of complex disease.

How many bad apples are in a bunch? An experimental investigation of perceived pesticide residue risks

Subjective risks of having contaminated apples elicited via the Exchangeability Method (EM) are examined in this study. In particular, as the experimental design allows us to investigate the validity of elicited risk measures, we examine the magnitude of differences between valid and invalid observations. In addition, using an econometric model, we also explore the effect of consumers’ socioeconomic status and attitudes toward food safety on subjects’ perceptions of pesticide residues in apples. Results suggest first, that consumers do not expect an increase in the number of apples containing only one pesticide residue, but, rather, in the number of those apples with traces of multiple residues. Second, we find that valid subjective risk measures do not significantly diverge from invalid ones, indicative of little effect of internal validity on the actual magnitude of subjective risks. Finally, we show that subjective risks depend on age, education, a subject’s ties to the apple industry, and consumer association membership.

Does climate change information affect stated risks of pine beetle impacts on forests? An application of the exchangeability method

Risks are an essential feature of future climate change impacts. We explore whether knowledge that climate change might be the source of increasing pine beetle impacts on public or private forests affects stated risk estimates of damage, elicited using the exchangeability method. We find that across subjects the difference between public and private forest status does not influence stated risks, but the group told that global warming is the cause of pine beetle damage has significantly higher risk perceptions than the group not given this information.

Farm animal welfare:Assessing risks attributable to the prenatal environment

An ever-expanding scientific literature highlights the impact of the prenatal environment on many areas of biology. Across all major farmed species, experimental studies have clearly shown that prenatal experiences can have a substantial impact on outcomes relevant to later health, welfare and productivity. In particular, stress or sub-optimal nutrition experienced by the mother during pregnancy has been shown to have wide-ranging and important effects on how her offspring cope with their social, physical and infectious environment. Variation in the conditions for development provided by the reproductive tract or egg, for instance by altered nutritional supply or hormonal exposure, may therefore explain a large degree of variation in many welfare- and productivity-relevant traits. The scientific literature suggests a number of management practices for pre-birth/hatch individuals that could compromise their later welfare. Such studies may have relevance for the welfare of animals under human care, depending on the extent to which real life conditions involve exposure to these practices. Overall, the findings highlight the importance of extending the focus on animal welfare to include the prenatal period, an aspect which until recently has been largely neglected. © 2012 Universities Federation for Animal Welfare The Old School.

Sharing services, saving money? Five risks to cost saving when organizations share administrative services

Shared services are a popular reform for governments under financial pressure. The hope is to reduce overheads and increase efficiency by providing support services like HR, finance and procurement once to multiple agencies. Drawing on insights from organization theory and political science, we identify five risks that shared services won’t live up to current expectations. We illustrate each with empirical evidence from the UK, Ireland and further afield, and conclude with suggestions on how to manage these risks.

SYSTEMATIC REVIEW AND META-ANALYSIS: EFFECTS OF WALKING EXERCISE IN CHRONIC MUSCULOSKELETAL PAIN

SYSTEMATIC REVIEW AND META-ANALYSIS: EFFECTS OF WALKING EXERCISE IN CHRONIC MUSCULOSKELETAL PAIN O'Connor S.R.1, Tully M.A.2, Ryan B.3, Baxter D.G.3, Bradley J.M.1, McDonough S.M.11University of Ulster, Health & Rehabilitation Sciences Research Institute, Newtownabbey, United Kingdom, 2Queen's University, UKCRC Centre of Excellence for Public Health (NI), Belfast, United Kingdom, 3University of Otago, Centre for Physiotherapy Research, Dunedin, New ZealandPurpose: To examine the effects of walking exercise on pain and self-reported function in adults with chronic musculoskeletal pain.Relevance: Chronic musculoskeletal pain is a major cause of morbidity, exerting a substantial influence on long-term health status and overall quality of life. Current treatment recommendations advocate various aerobic exercise interventions for such conditions. Walking may represent an ideal form of exercise due to its relatively low impact. However, there is currently limited evidence for its effectiveness.Participants: Not applicable.Methods: A comprehensive search strategy was undertaken by two independent reviewers according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and the recommendations of the Cochrane Musculoskeletal Review Group. Six electronic databases (Medline, CINAHL, PsychINFO, PEDro, Sport DISCUS and the Cochrane Central Register of Controlled Trials) were searched for relevant papers published up to January 2010 using MeSH terms. All randomised or non-randomised studies published in full were considered for inclusion. Studies were required to include adults aged 18 years or over with a diagnosis of chronic low back pain, osteoarthritis or fibromyalgia. Studies were excluded if they involved peri-operative or post-operative interventions or did not include a comparative, non exercise or non-walking exercise control group. The U.S. Preventative Services Task Force system was used to assess methodological quality. Data for pain and self-reported function were extracted and converted to a score out of 100.Analysis: Data were pooled and analyzed using RevMan (v.5.0.24). Statistical heterogeneity was assessed using the X2 and I2 test statistics. A random effects model was used to calculate the mean differences and 95% CIs. Data were analyzed by length of final follow-up which was categorized as short (≤8 weeks post randomisation), mid (2-12 months) or long-term (>12 months).Results: A total of 4324 articles were identified and twenty studies (1852 participants) meeting the inclusion criteria were included in the review. Overall, studies were judged to be of at least fair methodological quality. The most common sources of likely bias were identified as lack of concealed allocation and failure to adequately address incomplete data. Data from 12 studies were suitable for meta-analysis. Walking led to reductions in pain at short (<8 weeks post randomisation) (-8.44 [-14.54, -2.33]) and mid-term (>8 weeks - 12 month) follow-up (-9.28 [-16.34, -2.22]). No effect was observed for long-term (>12 month) data (-2.49 [-7.62, 2.65]). For function, between group differences were observed for short (-11.57 [-16.06, -7.08]) and mid-term data (-13.26 [-16.91, -9.62]). A smaller effect was also observed at long-term follow-up (-5.60 [-7.70, -3.50]).Conclusions: Walking interventions were associated with statistically significant improvements in pain and function at short and mid-term follow-up. Long-term data were limited but indicated that these effects do not appear to be maintained beyond twelve months.Implications: Walking may be an effective form of exercise for individuals with chronic musculoskeletal pain. However, further research is required which examines longer term follow-up and dose-response issues in this population.Key-words: 1. Walking exercise 2. Musculoskeletal pain 3. Systematic reviewFunding acknowledgements: Department of Employment and Learning, Northern Ireland.Ethics approval: Not applicable.