Papers by Kathryn Refshauge
British Journal of Sports Medicine, Apr 14, 2015
Clinicians aim to identify abnormalities, and distinguish harmful from harmless abnormalities. In... more Clinicians aim to identify abnormalities, and distinguish harmful from harmless abnormalities. In sports medicine, measures of physical function such as strength, balance and joint flexibility are used as diagnostic tools to identify causes of pain and disability and monitor progression in response to an intervention. Comparing results from clinical measures against 'normal' values guides decision-making regarding health outcomes. Understanding 'normal' is therefore central to appropriate management of disease and disability. However, 'normal' is difficult to clarify and definitions are dependent on context. 'Normal' in the clinical setting is best understood as an appropriate state of physical function. Particularly as disease, pain and sickness are expected occurrences of being human, understanding 'normal' at each stage of the lifespan is essential to avoid the medicalisation of usual life processes. Clinicians use physical measures to assess physical function and identify disability. Accurate diagnosis hinges on access to 'normal' reference values for such measures. However our knowledge of 'normal' for many clinical measures in sports medicine is limited. Improved knowledge of normal physical function across the lifespan will assist greatly in the diagnosis and management of pain, disease and disability.
BMC Complementary and Alternative Medicine, Jul 18, 2012
Background: The use of complementary and alternative medicine (CAM) has increased significantly i... more Background: The use of complementary and alternative medicine (CAM) has increased significantly in Australia over the past decade. Back pain represents a common context for CAM use, with increasing utilisation of a wide range of therapies provided within and outside conventional medical facilities. We examine the relationship between back pain and use of CAM and conventional medicine in a national cohort of mid-aged Australian women. Methods: Data is taken from a cross-sectional survey (n = 10492) of the mid-aged cohort of the Australian Longitudinal Study on Women's Health, surveyed in 2007. The main outcome measures were: incidence of back pain the previous 12 months, and frequency of use of conventional or CAM treatments in the previous 12 months. Results: Back pain was experienced by 77% (n = 8063) of the cohort in the previous twelve month period. The majority of women with back pain only consulted with a conventional care provider (51.3%), 44.2% of women with back pain consulted with both a conventional care provider and a CAM practitioner. Women with more frequent back pain were more likely to consult a CAM practitioner, as well as seek conventional care. The most commonly utilised CAM practitioners were massage therapy (26.5% of those with back pain) and chiropractic (16.1% of those with back pain). Only 1.7% of women with back pain consulted with a CAM practitioner exclusively. Conclusions: Mid-aged women with back pain utilise a range of conventional and CAM treatments. Consultation with CAM practitioners or self-prescribed CAM was predominantly in addition to, rather than a replacement for, conventional care. It is important that health professionals are aware of potential multiple practitioner usage in the context of back pain and are prepared to discuss such behaviours and practices with their patients.
BMJ Open, Dec 1, 2021
Introduction Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, ... more Introduction Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people's risk of poor outcome. Methods and analysis Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website ( mypainhub. com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration. Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media. Trial registration number ACTRN12619000871145.
ABSTRACT To determine if bioimpedance spectroscopy (BIS) could detect localised lymphoedema of th... more ABSTRACT To determine if bioimpedance spectroscopy (BIS) could detect localised lymphoedema of the arm and to compare BIS measurements with equivalent measures of limb volume by perometry. Women with mild to severe upper limb lymphoedema (n = 29) and women with no history of lymphoedema (n = 11) participated. Commencing at the ulnar styloid of the wrist, 4 × 10 cm segment measurements were made of each arm using both BIS and perometry. Average BIS inter-limb ratios for the total arm and each arm segment were higher than comparable perometry measures in women with lymphoedema, but similar to perometry measures for women without lymphoedema. Limits of agreement analysis showed that the mean difference between methods varied according to segment measured, ranging from 8.5% for the uppermost segment of the arm to 16.6% for the forearm segment just below the elbow. For all limb segments, there was a positive bias towards BIS measurements, which increased as lymphoedema severity increased. BIS can be used for localised measurement of lymphoedema. Because it is specific to extracellular fluid, BIS is more sensitive to localised lymphoedema than perometry.
Current Sociology, Jul 13, 2015
Chronic back pain is a major health and social problem in Australia, often concealed and given li... more Chronic back pain is a major health and social problem in Australia, often concealed and given limited credibility vis-a-vis other health conditions. Care practices are diversified with allied health, biomedical and complementary and alternative medicine (CAM) practitioners regularly being consulted for help and care, often concurrently. While this differentiated ‘healthcare market’ may on one level be viewed as positive in terms of diverse therapeutic choices, there is also potential for difficulties with regard to care practices and negotiating competing therapeutic modalities. Drawing on qualitative interviews with 50 women aged 60–65 from the Australian Longitudinal Study on Women’s Health living with chronic back pain, this article explores their accounts of suffering and the experiences of engaging in pluralistic healthcare choices, with a particular focus on CAM. The findings reveal the ways by which healthcare pluralism is connected to the dynamics of suffering and relations of recognition.
Clinical Rheumatology, Aug 15, 2013
Background: Back pain is a significant health service issue in Australia and internationally. Bac... more Background: Back pain is a significant health service issue in Australia and internationally. Back pain sufferers can draw upon a range of possible health care providers including complementary and alternative medicine (CAM) practitioners. Women are higher users of health services than men and tend to also use CAM frequently for musculoskeletal conditions. Despite recent work there remain important gaps in our understanding of women's consultation patterns with CAM practitioners for back pain. Objective: To examine the prevalence of use and characteristics of women who use complementary and alternative medicine practitioners for back pain. Methods: A cross-sectional postal survey from the nationally-representative sample of women aged 60-65 years from the Australian Longitudinal Study on Women's Health (ALSWH). The survey was completed by 1,310 women (response rate = 80.9%). Women consulted a massage therapist (44.1%, n=578) and a chiropractor (37.3%, n=488) more than other CAM practitioners for their back pain. Women's educational and income levels were not associated with their CAM practitioner consultations for back pain. Consultations with a chiropractor for back pain were lower for women who consulted a GP (OR: 0.56, 95% CI: 0.41, 0.76) or a physiotherapist (OR: 0.53, 95% CI: 0.39, 0.72) than for those who did not consult a GP or a physiotherapist. CAM practitioner consultations for back pain were greater for women who visited a pharmacist (OR: 1.99, 95% CI: 1.23, 3.32) than women who did not visit a pharmacist. There is substantial use of CAM practitioners alongside other more conventional practitioners amongst women for back pain and there is a need to provide detailed examination of the communication between patients and their providers as well as across the diverse range of health professionals involved in the care of back pain sufferers.
BMJ Open
IntroductionChronic disease is a leading cause of death and disability that disproportionately bu... more IntroductionChronic disease is a leading cause of death and disability that disproportionately burdens culturally and linguistically diverse (CALD) communities. Self-management is a cornerstone of effective chronic disease management. However, research suggests that patients from CALD communities may be less likely to engage with self-management approaches. The Natural Helper Programme aims to facilitate patient engagement with self-management approaches (ie, ‘activation’) by embedding cultural mentors with lived experience of chronic disease into chronic disease clinics/programmes. The Natural Helper Trial will explore the effect of cultural mentors on patient activation, health self-efficacy, coping efforts and health-related quality of life (HRQoL) while also evaluating the implementation strategy.Methods and analysisA hybrid type-1 effectiveness-implementation cluster-randomised controlled trial (phase one) and a mixed-method controlled before-and-after cohort extension of the t...
Journal of the American Medical Directors Association, 2022
OBJECTIVES The Sunbeam trial significantly reduced falls in long-term aged care (LTC) residents. ... more OBJECTIVES The Sunbeam trial significantly reduced falls in long-term aged care (LTC) residents. The current study's primary objective was to undertake subgroup analysis of the Sunbeam trial, to determine whether the intervention was effective for reducing falls in LTC residents with mild-moderate cognitive impairment/dementia. Secondary objectives were to determine intervention effects on cognitive and physical function. DESIGN Subgroup analysis of a cluster randomized controlled trial (RCT). SETTING AND PARTICIPANTS Permanent residents of LTC in Australia who participated in the Sunbeam trial with Addenbrooke's Cognitive Examination-Revised (ACE-R) scores <83 (Mini-Mental State Examination >14 = main trial inclusion criteria). METHODS Of 221 participants, 148 had an ACE-R <83 and were included in this study. Sixteen LTC residences (clusters) were randomized to receive either the Sunbeam program or usual care. The Sunbeam program involved two 1-hour sessions/week of tailored and progressive resistance and balance training for 25 weeks followed by a maintenance program (two 30-min sessions/week of nonprogressive exercise for 6 months). Assessments were conducted at baseline, 6 months, and 12 months. Falls were recorded using routinely collected data from the LTC incident management systems. RESULTS Rate of falls (50%) and risk of falls (31%), multiple falls (40%), and injurious falls (44%) were reduced in the intervention group. The intervention group had significantly better balance (static and dynamic) and sit-to-stand ability when compared with the control group at 6 months and significantly better dynamic balance at 12 months. There were no serious adverse events. CONCLUSIONS AND IMPLICATIONS The Sunbeam Program significantly reduced falls and improved physical performance in cognitively impaired LTC residents. This is a novel and important finding, as many previous studies have excluded people with cognitive impairment/dementia and inconsistent findings have been reported when this population has been studied. Our findings suggest that progressive resistance and balance exercise is a safe and effective fall prevention intervention in LTC residents with mild-moderate cognitive impairment/dementia.
Introduction: The factors causing chronic instability, a common sequela of ankle inversion sprain... more Introduction: The factors causing chronic instability, a common sequela of ankle inversion sprains are unclear, despite wide investigation. However, few studies have examined potential factors during the injuring movement. We therefore measured the ability of dancers to control ankle movement during quiet stance and after a perturbation into inversion in a group with chronic instability (N=16) and healthy controls (N=26). Methods: Control of ankle movement was determined by the magnitude of lateral oscillation at the ankle, measured by a 3SPACE Fastrak. The oscillation was measured during single leg stance (baseline oscillation) for two foot positions, flat and demi-pointe. In both positions, the time taken to return to the baseline oscillation after an inversion perturbation (perturbation time) of 15° for the flat foot and 7.5° for the demi-pointe position was also determined. Results: The baseline oscillation was significantly smaller (P Conclusions: Our findings demonstrate alter...
The Journal of Pain, 2021
Treatment outcomes for migraine and other chronic headache and pain conditions typically demonstr... more Treatment outcomes for migraine and other chronic headache and pain conditions typically demonstrate modest results. A greater understanding of underlying pain mechanisms may better inform treatments and improve outcomes. Increased GABA+ has been identified in recent studies of migraine, however, it is unclear if this is present in other headache and pain conditions. We primarily investigated GABA+ levels in the posterior cingulate gyrus (PCG) of people with migraine, whiplash-headache and low back pain compared to age- and sex-matched controls, GABA+ levels in the anterior cingulate cortex (ACC) and thalamus formed secondary aims. Using a cross-sectional design, we studied people with migraine, whiplash-headache or low back pain (n=56) and compared them with a pool of age-and sex-matched controls (n=22). We used spectral-edited magnetic resonance spectroscopy at 3T (MEGA-PRESS) to determine levels of GABA+ in the PCG, ACC and thalamus. PCG GABA+ levels were significantly higher in people with migraine and low back pain compared with controls (e.g. migraine 4.89 IU ± 0.62 versus controls 4.62 IU ± 0.38; p=0.02). Higher GABA+ levels in the PCG were not unique to migraine and could reflect a mechanism of chronic pain in general. A better understanding of pain at a neurochemical level informs the development of treatments that target aberrant brain neurochemistry to improve patient outcomes. PERSPECTIVE: This study provides insights into the underlying mechanisms of chronic pain. Higher levels of GABA+ in the PCG may reflect an underlying mechanism of chronic headache and pain conditions. This knowledge may help improve patient outcomes through developing treatments that specifically address this aberrant brain neurochemistry.
Journal of Clinical Oncology, 2013
e20533 Background: The aim of this single blinded RCT was to determine the effect of exercise on ... more e20533 Background: The aim of this single blinded RCT was to determine the effect of exercise on bone mineral density (BMD) in postmenopausal women prescribed an aromatase inhibitor (AI) for the treatment of breast cancer. Methods: 66 sedentary, postmenopausal women, median age of 54.5 years, with early breast cancer and receiving an aromatase inhibitor participated. Women were stratified for taking tamoxifen prior to AI, and randomised to either the exercise (n = 27) or control (n = 39) group. All participants received daily vitamin D (1000 IU) and calcium carbonate (1200 mg) supplements and a booklet from Osteoporosis Australia outlining the benefits of exercise in preventing osteoporosis. The exercise group attended a gym three times per week for one year, supervised at regular intervals by a personal trainer, and were contacted weekly regarding progress and progression. Training sessions comprised warm-up, impact training, and resistance training. The control group was contacted...
British Journal of Sports Medicine, 2018
Lateral ankle sprains are one of the most prevalent lower limb musculoskeletal injuries incurred ... more Lateral ankle sprains are one of the most prevalent lower limb musculoskeletal injuries incurred by individuals who participate in recreational physical activities and sports.1 2 ### Propensity for the development of chronic ankle instability The misconception that acute lateral ankle sprains are innocuous injuries that require little treatment is common across patients and healthcare professionals; indeed, up to 50% of individuals who incur an acute lateral ankle sprain do not seek formal healthcare management for their injury.3 All too often colloquial terms such as a ‘rolled’ ankle or ‘twisted’ ankle are used to describe an acute lateral ankle sprain injury. In reality, acute lateral ankle sprains are rarely ever a ‘simple’ injury. …
Archives of Physical Medicine and Rehabilitation, 2017
We thank Ray Patton and John Eisenhuth for technical support.
Journal of Science and Medicine in Sport, 2015
Background: In Judo, injuries are frequent and can be severe to the extent where athletes miss pr... more Background: In Judo, injuries are frequent and can be severe to the extent where athletes miss practice for long periods of time. Consequently, sport injury prevention for judo athletes is crucial. The aim of this study was to gather basic information that may assist in preventing sport injuries in judo, including physical fitness data collected from judo athletes when entering university as well as the rate and site of injuries during their collegiate careers. Methods: The period of this study was ten years, and the subjects consisted of 373 male judo athletes at a Japanese University. When entering the university, athletes completed a series of physical tests, including body composition (body fat percentage was derived from height, body mass and 3-site skinfold assessment using the calculations from Nagamine et al., 1979), isometric knee extension strength (calculated relative to body mass), muscular flexibility (hamstring, quadriceps, around shoulder girdle using the finger vertebral distance, gastrocnemius), joint laxity (knee hyperextension), and limb alignment (quadriceps-angle, varus and valgus knee alignment, foot pronation/supination). Throughout the athletes' collegiate careers, the number of injuries resulting in missing practice for a period of over one month was recorded and they were classified by site. Additionally, sport injuries with the highest numbers were divided into an injured group and a non-injured group, and their physical strength test data were compared for statistical difference. 'here were a total of 53 sport injuries: knee joint injuries (56%), foot joint injuries (13%), shoulder joint injuries (11%), elbow joint injuries (9%), back injuries (5%), finger injuries (4%), and neck injuries (2%). The subjects with knee joint injuries (n = 25) had significantly weaker knee extension muscle strength in the injured leg (77.7 ± 22.2% relative to body weight) when compared to the non-injured group (89.7 ± 22.2%, p < 0.01, n = 348). There were no significant differences between the 'knee-injured' and 'no injury' groups for any other physical testing results. Discussion: These results indicate that it is important to pay close attention to mainly knee joint injuries among judo athletes, and that knee extension muscle strength is crucial for its prevention. In Judo, this factor may be particularly vital due to the high frequency of situations when athletes must carry their own and their opponent's weight. As more data is collected about foot, shoulder, elbow and back injuries, it may be possible to perform similar analyses to establish links between other physical fitness characteristics and injury incidence.
Physiotherapy, 2015
Emphasis was placed on tester reliability for each measure used in this study and consequently me... more Emphasis was placed on tester reliability for each measure used in this study and consequently methodological studies establishing reliability and validity of measures were carried out and published. Results: The combination of baseline factors that predicted good clinical outcomes at different time points were: At 3 months: Age <40 years, Head neck angle < 40 • , NPAD scores < 55. Two of the three predictors generated a positive likelihood ratio of 10.15, which is a 10 fold increase (likelihood ratio 95% CI 3.4 to 30.7) for the individual to be a responder, increasing the post-test probability of success from 31% to 82%. At 12 months: Duration of symptoms ≥ 33 weeks, NPAD scores <55, Neck flexion <40 • , Rotation (right) >55 • . Two of the four predictors generated a 16 fold increase (likelihood ratio 95% CI 2.3 to 112) for the individual to be a responder and the post test probability of success increased to 94% from a pre-test probability of success at 50%. This study was able to identify predictor clusters that provide level IV evidence of predicting outcomes at different timelines in surgically treated patients for cervical radiculopathy. Implications: The results have an implication for future outcome studies in cervical radiculopathy research.
Cancer Research, 2015
Background: The incidence of secondary upper limb lymphedema after treatment for breast cancer is... more Background: The incidence of secondary upper limb lymphedema after treatment for breast cancer is unclear due to the wide variety of measurement tools and diagnostic thresholds that are used in both the literature and clinical practice. Furthermore, this lack of clarity in what constitutes lymphedema or not has prevented the progression of the field of lymphedema. Many of the thresholds have been chosen for ease of use only and have no evidence base to support them. The aim of this study, therefore, was to determine which clinical diagnostic threshold for unilateral upper limb lymphedema has the best sensitivity and specificity when compared to diagnosis by lymphoscintigraphy. Methods: Women with and without a history of secondary upper limb lymphedema were assessed using lymphoscintigraphy, bioimpedance spectroscopy (BIS) as well as volume and circumference measurements using the perometer. Dermal backflow score was determined as the diagnostic criteria for the lymphoscintigraphy and was assessed by an experienced nuclear medicine physician. Determination of the presence of lymphedema by lymphoscintigraphy was compared with diagnosis by both commonly-used and normatively-determined diagnostic thresholds for circumference, volume and bioimpedance. Results: For those with widespread dermal backflow, any clinical diagnostic criteria could differentiate between those with and without lymphedema. In contrast, for those with mild to moderate dermal backflow, only the normatively-determined threshold, set at 2 standard deviations above the norm, for arm circumference and full arm bioimpedance (Cornish et al 2001) had adequate sensitivity and specificity. Both of these thresholds had clinically relevant positive (23 and 10 respectively) and negative (0.2 and 0.3) likelihood ratios. Conclusion: Evidence-based diagnostic thresholds have been established for the diagnosis of secondary upper limb lymphedema. In determining if lymphoedema is present in those with mild lymphedema, normatively-determined circumference and bioimpedance thresholds that account for limb dominance should be used. Adoption of these evidence-based criteria will allow, for the first time, comparison between studies, clarifying the incidence and risk factors for lymphedema, allowing the field to make meaningful progress forward in determining who is at-risk for lymphedema and how to prevent it from developing. Acknowledgements: Cancer Australia and National Breast Cancer Foundation. Citation Format: Sharon L Kilbreath, Elizabeth S Dylke, Geoff P Schembri, Leigh C Ward, Dale L Bailey, Deborah Black, Elizabeth A Bailey, Jane M Beith, Kathryn M Refshauge. Determination of the first evidence-based diagnosis of secondary upper limb lymphedema [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-09.
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Papers by Kathryn Refshauge