Sports nutrition experts are commonly employed by professional collision sports teams to provide nutrition support to athletes, including guidance related to concussions and repeated head impacts. At present, there are limited clinical guidelines on which to base dietary advice regarding concussions, which may result in differing management approaches. This study aimed to explore the practices and perspectives of sports dietitians working in professional-level Australian collision sports (Australian Rules Football, Rugby League, and Rugby Union) regarding nutrition strategies for concussion management. Online semistructured interviews were conducted with 14 accredited sports dietitians. A qualitative, descriptive, and methodological approach guided data collection and analysis, with structured content analysis used to identify key categories. Quantitative summaries of supplement practices were also reported. Five categories were identified: 1) the dietitian's role in concussion management-dietitians considered themselves integral to multidisciplinary concussion management and were primarily involved after concussion; 2) nutrition strategies for concussion, which included dietary adjustments to manage symptoms and supplementation with fish oil and creatine monohydrate (93% of participants, respectively) to mitigate potential neurological sequelae; 3) confidence in management of concussion-dietitians felt confident in recommending strategies for concussion that were commonly used for other indications (e.g., creatine monohydrate supplementation for performance enhancement) but were less certain when providing tailored/individual recommendations, particularly in complex cases; 4) barriers to and enablers of recommendations that spanned from individual level (e.g., symptoms affecting dietary intake) to organizational level (e.g., financial resourcing to support supplementation protocols); and 5) differences in care between squads and codes and in care received by female and academy squads compared with their professional-level male counterparts. Sports dietitians in Australian collision sports actively contribute to concussion management, despite limited clinical guidelines. Further clinical research and the development of evidence-informed guidelines are critical to enhance the integration of nutrition into multidisciplinary concussion management and ensure optimal recovery for athletes.
To examine longitudinal associations between type 2 diabetes mellitus (T2DM) and work participation among Australians. Adults (≥18 years) from the Household, Income and Labour Dynamics in Australia Survey were followed from 2013 to 2017 and 2021. The exposure was T2DM status: prevalent (T2DM at baseline and follow-up), incident (no diabetes at baseline; T2DM at follow-up), or no diabetes. Outcomes were changes in work participation (transition out of or into employment) and patterns of weekly working hours (including persistent non-employment). Survey-weighted Poisson regression estimated adjusted incidence rate ratios (IRR); group-based trajectory modelling examined working hours patterns. Over four years, prevalent (adjusted IRR 1.57, 95%CI 1.09-2.25) and incident T2DM (adjusted IRR 1.59, 95%CI 1.12-2.25) were associated with transition out of employment, and incident T2DM with reduced transition into employment (adjusted IRR 0.22, 95%CI 0.09-0.56). These associations were no longer significant over eight years of follow-up. Prevalent T2DM was associated with persistent non-employment (adjusted odds ratio 2.04, 95%CI 1.44-2.88), and incident T2DM with lower odds of increasing working hours (adjusted odds ratio 0.44, 95%CI 0.22-0.88). T2DM is associated with reduced work participation, particularly immediately following diagnosis, highlighting the importance of early, targeted workplace support.
General practitioners (GPs) are central to the treatment and management of injured workers. Australian workers' compensation funds GP consultations for work-related injuries. Almost all other GP consultations are subsidised by public healthcare insurance (Medicare Benefit Scheme). This study aimed to examine changes in publicly-insured GP consultations before and after injury for injured workers with long-duration claims, focusing on consultation duration types and GP-provided mental health and chronic diseases management plans. This retrospective cohort study using interrupted time series analysis included 3,755 injured workers and 10,113 community individuals with injury/index date between 2006 and 2016. We compared monthly changes in rates (per 1000 workers) of six GP consultation types for 12-month before and 24-months after injury. Acute and long-term changes were examined both overall (combining all consultation types) and separately by consultation type. Consultation types include four duration-based levels: A (0-6 min), B (6-20 min), C (20-40 min), and D (40-60 min), and two types describing mental health and chronic disease management plans. After injury, injured workers received an additional 1,600 Medicare-subsidised GP consultations per 1,000 workers per year compared to the community group. Post-injury, the largest increase in monthly consultation rates was observed for Level D consultations (IRR: 2.37, 95% CI: 1.35, 4.20), while the smallest increment was observed for Level B consultations (IRR: 1.45, 95% CI: 1.32, 1.59). Monthly GP mental health care and chronic disease development plan rates increased by 84% (IRR: 1.84, 95% CI: 1.17, 2.93) and 20% (IRR: 1.20, 95% CI: 0.78, 1.86) post injury, respectively; however, the monthly rates of these consultations were small (maximum 25/1000 workers) Following these initial increases immediately post-injury, monthly consultation rates decreased by 3% to 9% and by 24-months post-injury had returned to levels observed in the comparison group. All six types of publicly insured GP consultations increased temporarily in the initial months following injury, regardless of worker's compensation status. These consultations remained elevated above pre-injury levels for over 12 months, likely reflecting delayed claim acceptance or increased care needs. These findings highlight the need of a comprehensive, whole-person approach to recovery that addresses both immediate and broader healthcare needs.
Intestinal failure-associated liver disease (IFALD) is a recognized complication of long-term parenteral nutrition (PN), with reported prevalence ranging from 25-85%, reflecting heterogeneity in patient populations, diagnostic criteria, and PN practices. We aimed to estimate the prevalence of IFALD in Australian adults receiving long-term home-PN (HPN), describe its biochemical and elastographic features, and identify predictors of IFALD. This was a single-centre, cross-sectional observational study in an Australian tertiary centre. Adults currently receiving long-term HPN (>12 weeks) or had received HPN within the previous decade were included. Patients with malignancy or pre-existing liver disease were excluded. IFALD was defined as persistent, unexplained elevation of liver function tests after exclusion of alternative causes of liver injury. Vibration controlled transient elastography (VCTE) was performed in all patients. Univariate logistic regression was used to evaluate associations between IFALD, nutritional, and biochemical variables. 24 patients were included. The median (inter-quartile range) duration of HPN was 42.5months (15.8-62.3); and weekly calories were 6647 kilocalories (3476.3-8471.3). 15 (62.5%) patients had IFALD. Cholestasis was the predominant biochemical pattern (80%). VCTE demonstrated significant fibrosis (≥ 8 kPa) in 20% and significant steatosis in 40% of IFALD patients. Ongoing HPN was the only variable significantly associated with IFALD on univariate analysis (OR=8, p=0.03). IFALD was highly prevalent and manifested as cholestatic liver injury, with a subset demonstrating elastographic evidence of fibrosis. Ongoing HPN was the main predictor, suggesting potential reversibility with PN cessation. Larger, multicentre studies are needed to identify any clinical predictors of IFALD.
Global population ageing continues to place pressure on health and care systems. In Australia, the increasing integration of health and aged care systems is a rising policy approach to alleviating the burden on the health system and improving the quality of care for older people. Preference-based instruments (PBMs) have become increasingly important as a tool to enable quality assessment and economic evaluation of both health and aged care services. Given the changing policy context towards more integrated services and older peoples' frequent movement across both health and aged care settings, it is important that PBMs are applicable across different care settings. This literature review aimed to assess the application of generic PBMs with older people across health and aged care settings. A systematic search of three databases for studies utilising PBMs with older people in health or aged care settings resulted in 204 articles included for review. The EQ-5D instruments were the most frequently utilised instrument across studies, followed by the Quality of Life-Aged Care Consumers (QOL-ACC). Most instruments were applied in either health or aged care settings, with few being used across both. The measurement of quality of life in older people across these settings using PBMs requires consideration of several issues particularly pertinent to this population, including the appropriateness, relevance and comprehensiveness of dimensions, the use of a suitable recall period and enabling self-report for people with cognitive impairment.
A variant of spontaneous movements "fidgety-like movements" has been described, but its prevalence and clinical relevance remain unclear. To describe the prevalence of "fidgety-like movements" at 3-5 months corrected age (CA), its relation to major cerebral lesions, and neurodevelopmental outcome in children born extremely preterm (EPT; <28 weeks gestation). A retrospective re-analysis was conducted using three General Movement Assessment datasets, including Motor Optimality Score-Revised (MOS-R) at 3-5 months CA, in 402 infants born EPT from cohorts in the Netherlands, Sweden and Australia. Follow-up age ranged 1-8 years. Neurodevelopmental outcomes were assessed using standardized assessments and ICD-10, and classified as typical or adverse. Twenty-six of 402 infants (7%; range 5-8%) (mean gestational age ± SD, 25.1 ± 1.4 weeks; birth weight 780.1 ± 202.1 g) showed "fidgety-like movements". Median (IQR) MOS-R was 22 (21-24). Eighteen (69%) were boys, 18 (69%) had bronchopulmonary dysplasia and two (8%) had severe brain lesions. Follow-up data were available for 25 children (96%): 12 (48%) had typical and 13 (52%) adverse outcomes. Of those with adverse outcomes, most were motor delay (n = 6, 24%), language delay (n = 5, 20%) and ADHD (n = 4, 16%) or combined, with only one case of CP (4%). Fifty-four percent of children had MOS-R < 23 (below cut-off for high risk of NDD). The rate of "fidgety-like movements" was 7% in infants born EPT. Only one infant developed CP; however, more than half of infants with "fidgety-like movements" had adverse outcomes and reduced MOS-R scores highlighting need for careful follow-up.
Microplastics and their associated toxic chemical compounds pose significant risks to both terrestrial and aquatic ecosystems. Risk evaluation commonly relies on three indices: the Pollution Load Index (PLI), Polymer Hazard Index (PHI), and Potential Ecological Risk Index (PERI), with each providing valuable yet isolated insight into different aspects of microplastics risk. The study areas included three urban creeks located in Southeast Queensland, Australia. Based on data obtained from individual sampling sites and multiple sampling rounds, PLI, PHI and PERI hotspot locations were identified. PHI and PERI values indicated a strong influence of hazardous polymer composition on toxicity-weighted ecological risk. Site-level Spearman correlation analysis showed that industrial, commercial, and residential land uses are positively associated with PLI, PHI, and PERI, whereas natural land use showed a negative correlation. A risk-zoning framework was developed based on elbow and silhouette analyses, which identified k = 3 as the optimal number of clusters, defining low, medium, and high-risk groups. Eight risk categories were then derived from these groups for finer operational risk classifications. These were expressed using a consistent hexadecimal colour scale derived from the 40 possible index-combination permutations. The resulting two-dimensional (2D) risk-zoning plots visualise how sediment microplastics are distributed across the combined risk space. Film and foam were identified as the most dominant shape compositions across all risk categories. The proposed innovative methodology offers a practical approach for identifying microplastic hotspots, interpreting risk-driving mechanisms, and supporting decision-making and policy formulation for targeted microplastics management and ecological protection strategies.
First metatarsophalangeal (MTP) joint osteoarthritis (OA) is a common and disabling condition that causes substantial pain and impairs quality of life. Cushioned insoles have the potential to lower plantar pressures beneath the hallux and possibly reduce pain, but their clinical effectiveness has not been investigated. This study describes the protocol for a randomised controlled trial (RCT) assessing whether daily use of cushioned insoles produces greater reductions in first MTP joint walking pain, and other symptoms, over 12 weeks than sham insoles. This two-arm, parallel group, superiority RCT will recruit 108 community-dwelling adults aged 45 years and older with symptomatic radiographic first MTP joint OA. Participants will be randomised to receive three pairs of either cushioned insoles (6 mm low-density ethyl vinyl acetate (EVA)) or visually similar thin sham insoles (2 mm high-density EVA), to be worn for 12 weeks. The primary outcome is the 12-week change in first MTP joint pain during walking, assessed using an 11-point numerical rating scale (0-10, higher scores worse pain). Secondary outcomes include 12-week changes in physical function, other measures of first MTP joint pain, health-related quality of life, physical activity, and fear of movement. Global ratings of change in pain and function will also be assessed at 12 weeks. Other measures will also be collected. Analyses will include all participants as randomised using linear and log-binomial regression adjusted for baseline values. Prespecified sensitivity and moderator analyses will also be conducted. This study has been approved by the University of Melbourne Greater than Low Risk Human Research Ethics Committee. Findings will provide the first evidence regarding the efficacy of cushioned insoles for the management of first metatarsophalangeal joint OA. Results will be disseminated via peer-reviewed journals, scientific conferences, information on our website and lay summaries for participants. Prospectively registered on the 14 of December 2023 with the Australian New Zealand Clinical Trials Registry, reference ACTRN12623001304628.
As climate extremes intensify, interactions among environmental drivers are expected to alter soil respiration (SR) and its response to rewetting, increasing uncertainty in carbon-climate feedbacks. However, the interactive effects of drought and warming, two commonly studied climate stressors, on SR remain elusive due to limited research and a lack of high-resolution data. This study investigated overall SR (SRoverall, encompassing both drying and rewetting phases) and rewetting-induced respiration pulses (SRpulse), along with their apparent sensitivity to temperature and moisture under factorial combinations of rainfall and warming treatments in a field-based climate-manipulation experiment conducted in a temperate pasture system in southeastern Australia. Rainfall extremes were derived from 30 years of regional climate records, while warming was imposed as a continuous, year-round increase of +3°C. An automated flux monitoring system was deployed to measure hourly SR across eight campaigns from October 2023 to November 2024. The drivers of SRoverall and SRpulse were identified by analyzing climatic variables together with soil parameters from rhizosphere and non-rhizosphere zones. Drought and warming consistently suppressed SRoverall but amplified SRpulse and moisture sensitivity. The interactive effects of both treatments on SRoverall varied seasonally, shifting from additive in spring to antagonistic in summer and autumn, and synergistic in winter. Drought suppressed apparent temperature sensitivity (Q10), but warming effects on Q10 varied with moisture conditions. Soil temperature, moisture, and extractable C:N ratio from across rhizosphere and non-rhizosphere soil were consistent predictors of SRoverall and SRpulse but exerted opposing effects on the two components. These findings advance our understanding of how drought-warming interactions shape both overall and pulse-driven SR, providing a process-based foundation for improving predictions of carbon-climate feedbacks under intensifying climate extremes.
Background Discharge from the ICU to the ward can be associated with negative outcomes. Local guidelines mandate documenting the occurrence and time of verbal handover between the ICU team and ward team to reduce this danger. However, adherence is inconsistent and incomplete. Objective This study aimed to improve the frequency and completeness of documented ICU-to-ward verbal handover using a human factors-informed intervention. The outcomes assessed were documentation-related process measures rather than handover quality or patient-centered clinical outcomes. Methods A closed-loop quality improvement project was conducted in a tertiary ICU in Sydney, Australia. Baseline data were collected over one week for all patients discharged to the ward (n=42 ICU discharges). Discharges home and patient deaths were excluded. A multifaceted intervention was implemented over two days, comprising a visual prompt, verbal reinforcement during a department meeting, and digital dissemination. The intervention was informed by human factors principles, aiming to reduce cognitive load and improve the reliability of safety-critical tasks. Re-audit was conducted four weeks later over another one-week period (n=43). Categorical data were analyzed using chi-squared (χ²) testing with significance set at p=0.05. One key limitation is that this study assessed documentation compliance and did not examine handover quality or patient outcomes. Results Documentation of verbal handover improved from 25/42 (59.5%) to 37/43 (86.0%), an absolute improvement of 26.5 percentage points (95% CI: 8.4 to 44.6; p=0.006). Documentation of handover timing improved from 9/25 (36.0%) to 30/37 (81.1%), an absolute improvement of 45.1 percentage points (95% CI: 22.4 to 67.7; p<0.001). Conclusion A simple, low-cost intervention informed by human factors principles significantly improved compliance with ICU discharge handover standards. By introducing environmental prompts and reducing reliance on memory-dependent processes, adherence to a safety-critical documentation process improved. More research is needed to assess the impact on patient care and the sustainability of change. This approach has the potential to be scalable, sustainable, and transferable to other high-risk transitions of care.
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Psychoactive substance use often begins during adolescence, and early initiation increases risks of problematic use and adverse health outcomes. Few evidence-based, technology-supported substance use prevention programs for adolescents exist in Europe. OurFutures (previously Climate Schools) is a web-based substance use prevention program developed in Australia that has been shown to improve substance-related knowledge and strengthen refusal and harm-minimization skills. This study aimed to adapt the OurFutures Alcohol and Cannabis course for German schools and to evaluate its feasibility and preliminary effectiveness. To strengthen the link between prevention and early intervention, the program was connected to the Mobile Online Portal for Questions on Addiction (MOFA), enabling students to access counseling services via chat, email, or telephone. The Alcohol and Cannabis course was adapted for the German school and addiction systems, and the online portal was created. Effectiveness and implementation were assessed in four German secondary schools using a controlled pilot study with quantitative surveys, complemented by exploratory qualitative feedback from a focus group (n = 2) and three individual interviews. Analyses of covariance demonstrated that the intervention group's knowledge about alcohol (n = 62) and cannabis (n = 63) increased significantly more than of controls (n = 28 and 31). No significant differences were observed for attitudes or intentions to use. Most students evaluated the Alcohol module positively and relevant. Qualitative findings indicated satisfaction among students and teachers, with suggestions for school implementation. This blended-learning program increased substance-related knowledge and may strengthen school-based prevention in Germany. Wider implementation requires coordination between education and addiction systems.
Transpalpebral electrical stimulation (TpES) has comparable therapeutic efficacy to transcorneal electrical stimulation (TcES) for retinal neurodegenerative disorders. Characterizing TpES-evoked visual cortical responses is critical to expand the clinical application of minimally invasive neuromodulation. We performed intrinsic optical signal imaging in the cat visual cortex to characterize spatiotemporal neurovascular coupling responses to independent-channel TpES, analyzed retinal electric field distribution via a human head computational model, with TcES as a control in both in vivo and simulation experiments. TpES evoked peripheral visual field cortical responses and retinal electric fields consistent with TcES patterns, with similar temporal dynamics. TpES amplitudes were comparable or significantly higher, indicating more efficient visual pathway activation. Our findings provide important evidence supporting the advancement and optimization of non-invasive stimulation techniques for the treatment of retinal neurodegenerative diseases.
Insufficient physical activity (PA) and excessive sedentary behaviour is associated with several cancers. Personalised approaches to increasing healthy movement behaviours over unhealthy behaviours may be more effective than a one-size-fits-all approach. Exploring both postures, and intensities across the 24-hour day may reveal actionable behavioural alternatives from current guidance. Using a novel dual-compositional approach, we assessed how differences in participant's composition of 24-hour daily movement (postures and intensities) and sleep are differentially associated with PA-related cancer incidence (a composite of 13 sites linked with physical inactivity). This prospective analysis involved adults drawn from the UK Biobank accelerometry subsample each followed-up by health linkage. Participant's daily movement was classified into two 24-hour compositions. Composition 1 (posture-focused): sleep duration, sedentary behaviour (SB), standing, moving at any intensity. Composition 2 (intensity-focused): sleep duration, sedentary time (ST), light PA (LPA), moderate PA (MPA), and vigorous PA (VPA). Secondary analysis combined VPA and MPA as moderate-to-vigorous PA (MVPA). PA-related cancer diagnoses were captured from health registry data for up to 9.5 years (y). Cox-proportional hazards models were adjusted for age, sex, education, smoking, alcohol, diet, parental cancer history, cardiovascular disease and medication use. Analyses included 59,218 (55% female) participants (mean [SD] age: 61.7 [7.8]y), with a median follow-up of 8.0y [IQR: 7.4-8.5y; 464,640 person years] with 2,385 (4%) incident cancer events. Among the average, active participant, greater moving in place of other behaviours was associated with lower cancer risk, e.g. theoretically replacing 15 min of sleep or SB with 15 min of moving was associated with hazard ratios (HR) of 0.98 (95% Confidence Interval (95%CI): 0.97-0.99) and 0.98 (95%CI: 0.97-0.99), respectively. Similar risk reduction was observed with 30 min additional standing in place of sleep or SB. Regarding intensity, greater MVPA, in place of any behaviour proved most robustly associated with lower risk, although notably, the VPA component within MVPA proved the critical intensity. Beyond MVPA, moving at any intensity, in place of other postures, was associated with reduced risk of cancer. However, greater standing may also provide a plausible behavioural adjunct or alternative, warranting further investigation.
To investigate the effect of peripheral scleral lens landing zone modifications upon short-term regional variations in corneal oedema. Nine healthy participants wore different scleral lens designs ((1) spherical landing zone, (2) toric landing zone, (3) peripheral notches, and (4) peripheral channels) in a randomised order on four separate days for 100 min. Stromal oedema was quantified using high-resolution optical coherence tomography across the central, mid-peripheral, and peripheral cornea with the lens in situ. Eye Surface Profiler (ESP) images were also captured following the application of 10 μL of 2% sodium fluorescein, over a period of 100 min. Central and peripheral fluorescent intensity data were extracted from the ESP images and analysed using customised software to quantify tear exchange. The channel lens design displayed less central oedema compared to the toric design (1.57 ± 0.45% less oedema, p = 0.04). In the corneal periphery, the magnitude of oedema was less for both the toric lens (2.66 ± 0.66% less oedema, p = 0.02) and the channel design (3.39 ± 0.97% less oedema, p = 0.04) in comparison to the spherical lens design. A highly significant correlation was observed between the magnitude of peripheral tear exchange after 90 min of lens wear and the magnitude of peripheral oedema (r = -0.61, p < 0.001). Scleral lenses with either a toric landing zone or peripheral channels exhibited less peripheral corneal oedema than a spherical landing zone design, due to enhanced peripheral tear exchange.
Clinical AI assumes that the influence of training data can persist indefinitely. This premise fails when patients withdraw consent, evidence evolves, or bias is identified. Machine unlearning aims to remove specific data influence without full retraining. We argue that unlearning readiness should be built into the infrastructure of high-risk healthcare AI across patient autonomy, clinical validity, and system governance, and we outline a governance pathway to keep updates auditable and clinically safe.
To evaluate the diagnostic performance of fecal elastase (FE) in exocrine pancreatic insufficiency (EPI) and examine the risk factors for EPI in children with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). We analyzed prospectively collected demographic, clinical, and EPI data of children with ARP or CP (n=1007) enrolled in the INSPPIRE-2 (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) consortium. FE performance was assessed against individual markers of fat malabsorption and a composite reference standard in which the presence of any 1 of the following was considered consistent with fat malabsorption in lieu of a gold-standard pancreas function test: (1) clinical diagnosis of EPI, (2) vitamin A or E deficiency, or (3) BMI z-score ≤-2. Cox regression models were used to identify predictors of EPI. EPI was diagnosed in 195/1007 (19.4%) children with ARP/CP, with FE being the most commonly used diagnostic tool. FE demonstrated low sensitivity (55.8% and 65.1%), moderate specificity (82.8% and 75.5%), and a high negative predictive value (92% and 93%), at cut-offs of 100 μg/g and 200 μg/g stool, respectively, in detecting at least 1 marker of fat malabsorption. The 7-year cumulative incidence of EPI after the first pancreatitis episode was 24%. Genetic risk factors were associated with earlier progression to EPI (HR 1.56; 95% CI 1.02-2.39). EPI affects nearly 20% of children with ARP/CP. FE is a valuable diagnostic tool in ruling out EPI. Children with genetic risk factors need closer surveillance due to an increased risk for developing EPI.
As we care for a globally aging patient population, it is important that infectious diseases randomized controlled trials (RCTs) reflect these demographic changes with adequate representation of older adults. Using a dataset of published infectious diseases RCTs, we aimed to evaluate the inclusion of older adults based on trial eligibility criteria and reporting of relevant geriatric characteristics. We conducted a secondary analysis of a previously published systematic review of infectious diseases RCTs published between January 2014 and August 2023 in ten high-impact journals. We assessed the overall proportion of RCTs that included older adults (defined as ≥65 years), stratified by country income and subject area, and evaluated predictors of whether a study excluded older adults using logistic regression. We also assessed whether studies reported key geriatric characteristics including frailty, functional status, cognition, and place of residence. There were 1093 RCTs that included adults ≥18 years; 207 (18.9%) excluded older adults by design. The weighted mean age by trial size across all included studies that reported a mean age (n=1029) was 53.5 years, which differed across trial subject area and country income. Participants in trials conducted in high-income countries (n=581 studies; weighted mean age 63.7 years) were older than those conducted in mixed income (n=168 studies; 49.8 years) and low-income countries (n=272 studies, 27.8 years). Studies conducted exclusively in older adults (n=19, 1.7%) were more likely to report at least one geriatric characteristic of interest (n=8/19 studies, 42.1%) compared with all studies that included older adults (n=55/886 studies, 6.2%, χ2=37.0, p<0.0001). Older adults remain underrepresented in infectious diseases RCTs. Their inclusion is essential in ensuring generalizability of results to the population encountered in clinical practice. Geriatric characteristics remain underreported even in geriatric-focused RCTs despite the heterogeneity of older adults.
Large language models (LLMs) including GPT-4 are increasingly used to generate health information, but concerns persist about their accuracy and relevance, particularly for elite athletes. This study used GPT-4-generated frequently asked question (FAQ) responses on sleep and jet lag as the starting material for expert evaluation and consensus development, with the goal of producing consensus-based, athlete-specific guidance while identifying the limitations of AI-generated content. Between November 2024 and March 2025, n = 17 international sleep and circadian experts from the Athlete Travel & Sleep Interest Group (ATSIG) participated in a two-round Delphi process. Experts rated 20 GPT-4-generated FAQ responses (10 on sleep, 10 on jet lag) for appropriateness using a 6-point Likert scale and provided qualitative feedback. Items were revised after round 1 using inductive thematic coding. Consensus was defined as ≥ 70% of participants rating an item as appropriate (scores 5-6) and ≤ 15% as non-appropriate (scores 1-2). Statistical analyses included Wilcoxon signed-rank tests, convergence metrics and dissent detection (outlier and bipolarity analysis). In round 1, 15 of 20 items (75%) met consensus; by round 2, 18 of 20 (90%) achieved consensus. For sleep items, 7 of 10 reached consensus in round 1 and 9 in round 2; for jet lag, 8 items reached consensus in round 1 and 9 in round 2. Sleep Q6 (sleep and injury risk) narrowly missed the consensus threshold with 64.7% agreement, while Jet Lag Q9 (melatonin and sleep aids) remained below the 70% threshold. No item showed bimodal score distributions, suggesting no polarized disagreement. Descriptive rating patterns, increased consensus and qualitative expert feedback indicated improved clarity, accuracy and athlete-specific relevance after the Delphi process, although item-level statistical comparisons did not remain significant after Bonferroni correction for multiple testing. Qualitative analysis identified common concerns: for sleep items-imprecise or misleading content (55%), lack of athlete-specific relevance (30%) and outdated evidence (11%); for jet lag-outdated evidence (36%), imprecise or misleading content (34%) and formatting issues (17%). GPT-4-derived content may serve as useful preliminary material for expert discussion but should not be used as standalone guidance. Expert evaluation improved the clarity, safety and athlete-specific relevance of most sleep and jet-lag responses, while the final outputs should be interpreted as consensus-based guidance rather than definitive proof of correctness.
The biopsychosocial (BPS) model is widely endorsed as best practice in musculoskeletal (MSK) physiotherapy. However, its implementation often remains constrained by biomedical assumptions, with psychosocial approaches primarily used to improve adherence, reduce symptoms, or restore function. As a result, contemporary BPS practice risks becoming "biomedical-plus" care rather than a genuinely integrated approach. We argue that physiotherapists can move toward a more authentic application of the BPS model through three interconnected foundational conditions - the 3Cs: professional Confidence, role Clarity, and Compassionate communication. Together, these foundational conditions support physiotherapists in engaging with the emotional, relational, and social dimensions of pain. Many physiotherapists report uncertainty when addressing trauma, psychological distress, or social determinants of health, often due to limited training, lack of supervision, and fragmented interdisciplinary systems. Rigid professional boundaries may discourage meaningful engagement with psychosocial and social contributors to pain, while entrenched patient expectations for biomedical explanations and passive treatments can make person-centred BPS conversations challenging. Addressing these barriers requires a shift from viewing psychosocial care as an "add-on" toward understanding pain within broader relational and social contexts. Authentic BPS physiotherapy requires educational reform, interdisciplinary collaboration, supportive service structures, and communication approaches that validate lived experience while promoting meaningful participation. By strengthening Confidence, Clarity, and Compassion, physiotherapists are well positioned to support not only physical recovery but also self-management, social connection, autonomy, and engagement in valued life roles.