1
|
Newton C, Singh G, Nolan D, Booth V, Diver C, O'Neill S, Purtill H, Logan P, O'Sullivan K, O'Sullivan P. Cognitive Functional Therapy compared with usual physiotherapy care in people with persistent low back pain: a mixed methods feasibility randomised controlled trial in the United Kingdom National Health Service. Physiotherapy 2024; 123:118-132. [PMID: 38479068 DOI: 10.1016/j.physio.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 12/12/2023] [Accepted: 02/06/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES To determine the feasibility of completing a definitive randomised controlled trial (RCT), evaluating the clinical and cost-effectiveness of Cognitive Functional Therapy (CFT) in comparison to usual physiotherapy care (UPC), for people with persistent low back pain (LBP). DESIGN AND SETTING A two-arm parallel feasibility RCT completed in a United Kingdom (UK) Secondary Care National Health Service (NHS) physiotherapy service. PARTICIPANTS Sixty adult participants who reported LBP lasting for more than three months, that was not attributable to a serious (e.g. cancer) or specific (e.g. radiculopathy) underlying cause, were invited to participate. Participants were allocated at random to receive CFT or UPC. INTERVENTIONS Cognitive Functional Therapy and Usual Physiotherapy Care for persistent LBP. MAIN OUTCOME MEASURES The primary outcome was the feasibility of completing a definitive RCT, defined by recruitment of at least 5 participants per month, delivery of CFT per protocol and securing relevant and acceptable outcome measures. Data concerning study processes, resources, management and participant reported outcome measures were collected at baseline, 3, 6 and 12-month follow-up. RESULTS Sixty participants (n = 30 CFT and n = 30 UPC) were recruited with 80% (n = 48), 72% (n = 43) and 53% (n = 32) retained at 3, 6 and 12-month follow-up respectively. NHS physiotherapists were trained to competence and delivered CFT with fidelity. CFT was tolerated by participants with no adverse events. Relevant and clinically important outcome data were collected at all time points (0.4%, 3%, 1% and 0.8% of data was missing from the returned outcome measure booklets at baseline and 3, 6 and 12-month follow-up respectively). The Roland-Morris disability questionnaire was considered the most suitable primary outcome measure with a proposed sample size of 540 participants for a definitive cluster RCT. CONCLUSION It is feasible to conduct a randomised study of CFT in comparison to UPC for NHS patients. A future study should incorporate an internal pilot to address aspects of feasibility further, including participant retention strategies. CLINICAL TRIAL REGISTRATION NUMBER ISRCTN12965286 CONTRIBUTION OF THE PAPER.
Collapse
Affiliation(s)
- Christopher Newton
- Centre of Rehabilitation and Ageing Research, School of Medicine, University of Nottingham, UK; Physiotherapy Department, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Gurpreet Singh
- Physiotherapy Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - David Nolan
- Physiotherapy Department, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Vicky Booth
- Centre of Rehabilitation and Ageing Research, School of Medicine, University of Nottingham, UK
| | - Claire Diver
- Centre of Rehabilitation and Ageing Research, School of Medicine, University of Nottingham, UK
| | - Seth O'Neill
- School of Allied Health Professions, College of Life Sciences, University of Leicester, Leicester, UK
| | - Helen Purtill
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Pip Logan
- Centre of Rehabilitation and Ageing Research, School of Medicine, University of Nottingham, UK
| | - Kieran O'Sullivan
- School of Allied Health, University of Limerick, Limerick, Ireland; Ageing Research Centre, University of Limerick, Limerick, Ireland; Sports and Human Performance Research Centre, University of Limerick, Limerick, Ireland
| | - Peter O'Sullivan
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| |
Collapse
|
2
|
Furness J, Phillips J, Canetti E, Kemp-Smith K. Exploring mental health approaches and curriculum in physiotherapy: an Australasian perspective. Physiother Theory Pract 2024:1-15. [PMID: 38368604 DOI: 10.1080/09593985.2024.2316308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/08/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Exposure to mental health problems are becoming increasingly more frequent within physiotherapy. Physiotherapists recognize the need for a biopsychosocial approach, however their knowledge, assessment, and treatment skills specific to mental health problems requires further research. PURPOSE To profile the level of education and perception of education that physiotherapists have acquired specific to mental health problems; and to profile an understanding of the current practice of physiotherapists specific to mental health problems. METHODS An online survey addressed the aims of the study and collected data from physiotherapists in Australia and New Zealand (open between 20th of October 2022 to the 20th of March 2023). RESULTS 139 respondents were included in the analysis. Physiotherapists had a perception that a significantly greater amount of coursework related to mental health needed to be included within their initial degree compared to what they received (mean difference of 20.0%, 95% CI: 17.5 to 22.5). This trend was evident irrespective of the degree level or the year of graduation. Higher perceived knowledge of anxiety (MD of 11.4, p = 0.001, ES: 0.5) and depression (MD of 11.8, p = 0.001, ES: 0.5) was evident in outpatient care physiotherapists. Lack of perceived knowledge is a reason for whether an assessment or treatment strategy is used with patients experiencing a mental health problem. Motivational interviewing and mindfulness were the most frequently used psychologically based techniques. CONCLUSION This study reveals the need to increase the amount of mental health and psychologically based techniques within Physiotherapy curriculum.
Collapse
Affiliation(s)
- J Furness
- Faculty of Health Science and Medicine. Bond Institute of Health and Sport Bond University, Robina, Gold Coast, Queensland, Australia
| | - J Phillips
- Faculty of Health Science and Medicine. Bond Institute of Health and Sport Bond University, Robina, Gold Coast, Queensland, Australia
- The Wesley Hospital, Uniting Care Health, Auchenflower, Brisbane, Queensland, Australia
| | - E Canetti
- Faculty of Health Science and Medicine. Bond Institute of Health and Sport Bond University, Robina, Gold Coast, Queensland, Australia
| | - K Kemp-Smith
- Faculty of Health Science and Medicine. Bond Institute of Health and Sport Bond University, Robina, Gold Coast, Queensland, Australia
| |
Collapse
|
3
|
Sohanpal R, Pinnock H, Steed L, Heslop-Marshall K, Kelly MJ, Chan C, Wileman V, Barradell A, Dibao-Dina C, Font Gilabert P, Healey A, Hooper R, Mammoliti KM, Priebe S, Roberts M, Rowland V, Waseem S, Singh S, Smuk M, Underwood M, White P, Yaziji N, Taylor SJ. A tailored psychological intervention for anxiety and depression management in people with chronic obstructive pulmonary disease: TANDEM RCT and process evaluation. Health Technol Assess 2024; 28:1-129. [PMID: 38229579 PMCID: PMC11017633 DOI: 10.3310/pawa7221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
Background People with chronic obstructive pulmonary disease have high levels of anxiety and depression, which is associated with increased morbidity and poor uptake of effective treatments, such as pulmonary rehabilitation. Cognitive-behavioural therapy improves mental health of people with long-term conditions and could potentially increase uptake of pulmonary rehabilitation, enabling synergies that could enhance the mental health of people with chronic obstructive pulmonary disease. Aim Our aim was to develop and evaluate the clinical effectiveness and cost effectiveness of a tailored cognitive-behavioural approach intervention, which links into, and optimises the benefits of, routine pulmonary rehabilitation. Design We carried out a pragmatic multicentre randomised controlled trial using a 1.25 : 1 ratio (intervention : control) with a parallel process evaluation, including assessment of fidelity. Setting Twelve NHS trusts and five Clinical Commissioning Groups in England were recruited into the study. The intervention was delivered in participant's own home or at a local NHS facility, and by telephone. Participants Between July 2017 and March 2020 we recruited adults with moderate/very severe chronic obstructive pulmonary disease and mild/moderate anxiety and/or depression, meeting eligibility criteria for assessment for pulmonary rehabilitation. Carers of participants were invited to participate. Intervention The cognitive-behavioural approach intervention (i.e. six to eight 40- to 60-minute sessions plus telephone support throughout pulmonary rehabilitation) was delivered by 31 trained respiratory healthcare professionals to participants prior to commencing pulmonary rehabilitation. Usual care included routine pulmonary rehabilitation referral. Main outcome measures Co-primary outcomes were Hospital Anxiety and Depression Scale - anxiety and Hospital Anxiety and Depression Scale - depression at 6 months post randomisation. Secondary outcomes at 6 and 12 months included health-related quality of life, smoking status, uptake of pulmonary rehabilitation and healthcare use. Results We analysed results from 423 randomised participants (intervention, n = 242; control, n = 181). Forty-three carers participated. Follow-up at 6 and 12 months was 93% and 82%, respectively. Despite good fidelity for intervention delivery, mean between-group differences in Hospital Anxiety and Depression Scale at 6 months ruled out clinically important effects (Hospital Anxiety and Depression Scale - anxiety mean difference -0.60, 95% confidence interval -1.40 to 0.21; Hospital Anxiety and Depression Scale - depression mean difference -0.66, 95% confidence interval -1.39 to 0.07), with similar results at 12 months. There were no between-group differences in any of the secondary outcomes. Sensitivity analyses did not alter these conclusions. More adverse events were reported for intervention participants than for control participants, but none related to the trial. The intervention did not generate quality-of-life improvements to justify the additional cost (adjusted mean difference £770.24, 95% confidence interval -£27.91 to £1568.39) to the NHS. The intervention was well received and many participants described positive affects on their quality of life. Facilitators highlighted the complexity of participants' lives and considered the intervention to be of potential valuable; however, the intervention would be difficult to integrate within routine clinical services. Our well-powered trial delivered a theoretically designed intervention with good fidelity. The respiratory-experienced facilitators were trained to deliver a low-intensity cognitive-behavioural approach intervention, but high-intensity cognitive-behavioural therapy might have been more effective. Our broad inclusion criteria specified objectively assessed anxiety and/or depression, but participants were likely to favour talking therapies. Randomisation was concealed and blinding of outcome assessment was breached in only 15 participants. Conclusions The tailored cognitive-behavioural approach intervention delivered with fidelity by trained respiratory healthcare professionals to people with chronic obstructive pulmonary disease was neither clinically effective nor cost-effective. Alternative approaches that are integrated with routine long-term condition care are needed to address the unmet, complex clinical and psychosocial needs of this group of patients. Trial registration This trial is registered as ISRCTN59537391. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/146/02) and is published in full in Health Technology Assessment; Vol. 28, No. 1. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Ratna Sohanpal
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Liz Steed
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Moira J Kelly
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Claire Chan
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Vari Wileman
- School of Mental Health and Psychological Sciences, Institute of Psychiatry, King's College London, London, UK
| | - Amy Barradell
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Paulino Font Gilabert
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | - Andy Healey
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | - Richard Hooper
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Kristie-Marie Mammoliti
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Priebe
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mike Roberts
- Safer Care Victoria, Melbourne, Melbourne, VIC, Australia
| | | | | | - Sally Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Melanie Smuk
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick White
- Department of Population Health, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Nahel Yaziji
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK
| | - Stephanie Jc Taylor
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
4
|
Chowdhury AR, Schofield D, Shrestha R, Nicholas M. Economic analysis of patient-related effects of an interdisciplinary pain self-management program. Pain 2023; 164:2491-2500. [PMID: 37326690 PMCID: PMC10578420 DOI: 10.1097/j.pain.0000000000002959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 12/09/2022] [Accepted: 04/25/2023] [Indexed: 06/17/2023]
Abstract
ABSTRACT Active Day Patient Treatment (ADAPT) is a well-established 3 week intensive cognitive-behavioural, interdisciplinary pain management program for patients with disabling chronic pain. The aim of this analysis was to conduct an economic analysis of patient-related effects of ADAPT using hospital administrative data, specifically, to compare the costs and health outcomes for patients 1 month after participating in the program, with the preprogram period when they were receiving standard care. This retrospective cohort study included 230 patients who completed ADAPT (including follow-ups) between 2014 and 17 at the Pain Management and Research Centre at the Royal North Shore Hospital in Sydney, Australia. Data on pain-related healthcare utilization and costs before and after the program were assessed. Primary outcome measures were labour force participation for patients' average weekly earnings and cost per clinically meaningful change in Pain Self-efficacy Questionnaire, Brief Pain Inventory (BPI) Severity, and BPI interference scores (n = 224). We estimated patients, on average, earned $59 more each week at 1 month follow-up compared with baseline. The cost per clinically meaningful change in pain severity and interference score based on the BPI severity and BPI interference were AU$9452.32 (95% CI: $7031.76-$12,930.40) and AU$3446.62 (95% CI: $2851.67-$4126.46), respectively. The cost per point improvement and per clinically meaningful change in the Pain Self-efficacy Questionnaire were $483 (95% CI: $411.289-$568.606) and $3381.02, respectively. Our analysis showed a better health outcome, reduced healthcare services' cost, and reduced number of medications taken 1 month after participating in ADAPT.
Collapse
Affiliation(s)
| | - Deborah Schofield
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie Business School, Macquarie University, Australia
| | - Rupendra Shrestha
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie Business School, Macquarie University, Australia
| | - Michael Nicholas
- Pain Management Research Institute, Sydney Medical School, University of Sydney, Australia
| |
Collapse
|
5
|
Laksono RM, Siswagama TA, Asmoro AA, Sjahrir H, Musba AM, Halim W, der Weegen WV, Vissers K. Identifying pain problems, healthcare professional perceptions, expectations and challenges in multidisciplinary pain center establishment. Pain Manag 2023; 13:385-395. [PMID: 37458192 DOI: 10.2217/pmt-2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Aim: Before establishing a multidisciplinary pain center (MPC), the pain problem, healthcare professionals (HCP) perceptions, expectations and the potential challenges of MPC establishment need to be identified. Methods: A quantitative survey study of 1058 Indonesian HCPs. The study uses a national inquiry sent by the International Association for the Study of Pain (IASP) chapter for pain. Results: 99.0% of respondents had met patients with pain as the primary complaint and acute pain as the most common complaint. Insufficient pain management in Indonesian healthcare, insufficient pain epidemiological data and unaware HCP about MPC become problems of pain management in Indonesia. However, most HCP agreed that health facilities should have MPC. Financial issues (insufficient patient insurance) were considered the most important barrier for referring patients to MPC. Conclusion: The identified core problem, HCP perceptions, expectations and challenges of MPC establishment should become a consideration in the strategic planning of MPC establishment.
Collapse
Affiliation(s)
- Ristiawan M Laksono
- Department of Anesthesiology & Intensive Therapy, Faculty of Medicine, Brawijaya University, Malang, Indonesia
| | - Taufiq A Siswagama
- Department of Anesthesiology & Intensive Therapy, Faculty of Medicine, Brawijaya University, Malang, Indonesia
| | - Aswoco A Asmoro
- Department of Anesthesiology & Intensive Therapy, Faculty of Medicine, Brawijaya University, Malang, Indonesia
| | - Hasan Sjahrir
- Department of Neurology, Faculty of Medicine, Sumatera Utara University, Medan, Indonesia
| | - Andi Mt Musba
- Department of Anesthesiology, Intensive Care & Pain Management, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Willy Halim
- Department of Medicine, Faculty of Medicine, Brawijaya University, Malang, Indonesia
| | | | - Kris Vissers
- Department of Anesthesiology, Pain & Palliative Medicine, Radboud University Medical Centre, The Netherlands
| |
Collapse
|
6
|
Abstract
AIM To examine and describe the current evidence about occupational therapy services in primary care. BACKGROUND Interprofessional primary care teams have been introduced to support the changing demographics and provide more comprehensive and coordinated care. Occupational therapists have the opportunity to play an important role in this expanding area of practice. To do so, occupational therapists must develop roles built on evidence and a clear understanding of the care delivery context. METHODS A scoping review was conducted based on the scientific and grey literature. Studies that described or examined the occupational therapy role with clients (individuals, groups, communities, populations) of all ages, conditions or occupational issues in a primary care context and that presented or referred to an occupational therapist working in a primary care setting were included. Studies were excluded if they were not in English or French. The Canadian Model of Occupational Performance and Engagement was used to chart the data. FINDINGS 129 articles were identified, with 62 non-research and 67 research-focussed articles. A total of 268 assessments and 868 interventions were identified. The top interventions offered by occupational therapists were referring to/advocating for/coordinating/linking to and navigating community services (n = 36 articles), chronic disease management (n = 34 articles)/self-management education (n = 28 articles), health promotion (n = 30 articles) and falls prevention (n = 27 articles). The predominant focus in the literature is on adult and older adult populations.
Collapse
|
7
|
Bennett SE, Almeida C, Bachmair EM, Gray SR, Lovell K, Paul L, Wearden A, Macfarlane GJ, Basu N, Dures E. Therapists' experiences of remotely delivering cognitive-behavioural or graded-exercise interventions for fatigue: a qualitative evaluation. Rheumatol Adv Pract 2022; 6:rkac083. [PMID: 36340509 PMCID: PMC9629972 DOI: 10.1093/rap/rkac083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 10/04/2022] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE Fatigue is a challenging feature of all inflammatory rheumatic diseases. LIFT (Lessening the Impact of Fatigue in inflammatory rheumatic diseases: a randomized Trial) included remotely delivered personalized exercise programme (PEP) or cognitive-behavioural approach (CBA) interventions. The aim of this nested qualitative evaluation was to understand rheumatology health professionals' (therapists') perspectives of delivering the interventions in the LIFT trial. METHODS A subgroup of therapists who had delivered the personalized exercise programme (PEP) and cognitive-behavioural approach (CBA) interventions took part in semi-structured telephone interviews. RESULTS Seventeen therapists (13 women and 4 men) who delivered PEP (n = 8) or CBA (n = 9) interventions participated. Five themes were identified. In 'The benefits of informative, structured training', therapists described how they were able to practice their skills, and the convenience of having the LIFT manual for reference. When 'Getting into the swing of it', supporting patients gave therapists the confidence to tailor the content of the manual to each patient. Clinical supervision supported therapists to gain feedback and request assistance when required. In 'Delivering the intervention', therapists reported that patients valued the opportunity to talk about their fatigue and challenge their beliefs. In 'Challenges in delivering the LIFT intervention', therapists struggled to work in partnership with patients who lacked motivation or stopped engaging. Finally, in 'LIFT developing clinical skills', therapists gained confidence and professional satisfaction, seeing patients' fatigue improve over time. CONCLUSION The findings support the provision of training for rheumatology health professionals to remotely deliver fatigue-management interventions. Insights from these trials can be used to better improve clinical practice and service provision.
Collapse
Affiliation(s)
- Sarah E Bennett
- Correspondence to: Sarah E. Bennett, Translational Health Sciences, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK. E-mail:
| | - Celia Almeida
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
| | - Eva-Maria Bachmair
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen, UK
| | - Stuart R Gray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Lorna Paul
- School of Health and Life Science, Glasgow Caledonian University, Glasgow, UK
| | - Alison Wearden
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Gary J Macfarlane
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | | |
Collapse
|
8
|
Nicklas L, Albiston M, Dunbar M, Gillies A, Hislop J, Moffat H, Thomson J. A systematic review of economic analyses of psychological interventions and therapies in health-related settings. BMC Health Serv Res 2022; 22:1131. [PMID: 36071425 PMCID: PMC9450839 DOI: 10.1186/s12913-022-08158-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 05/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background This review aims to synthesise evidence on the economic impact of psychological interventions and therapies when applied to a broad range of physical health conditions. Methods The following bibliographic databases were searched for relevant articles: MEDLINE (Ovid), EMBASE (Ovid) and PsycINFO (Ebsco). As this review was intended to update an earlier review, the date range for the search was restricted to between January 2012 and September 2018. Reference lists from the review articles were also searched for relevant articles. Study quality was evaluated using the Scottish Intercollegiate Network Guidelines (SIGN) appraisal checklists for both economic studies and Randomised Controlled Trials (RCTs). When the economic analyses did not provide sufficient detail for quality evaluation, the original RCT papers were sought and these were also evaluated. Half of the papers were quality rated by a second author. Initial agreement was high and all disagreements were resolved by discussion. Results This yielded 1408 unique articles, reduced to 134 following screening of the title and abstract. The full texts of the remaining articles were reviewed by at least one team member and all exclusions were discussed and agreed by the team. This left 46 original research articles, alongside five systematic reviews. Fifty-seven per cent of the articles were deemed to be of high quality, with the remainder of acceptable quality. Fifteen different medical conditions were covered, with chronic pain (10 articles) and cancer (9 articles) being the two most investigated health conditions. Three quarters of the papers reviewed showed evidence for the cost-effectiveness of psychological interventions in physical health, with the clearest evidence being in the field of chronic pain and cancer. Conclusions This paper provides a comprehensive integration of the research on the cost-effectiveness of psychological therapies in physical health. Whilst the evidence for cost-effectiveness in chronic pain and cancer is encouraging, some health conditions require further study. Clearly, as the primary research is international, and was therefore conducted across varying health care systems, caution must be exercised when applying the results to counties outside of those covered. Despite this, the results are of potential relevance to service providers and funders. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08158-0.
Collapse
Affiliation(s)
- Leeanne Nicklas
- NHS Education for Scotland, 2 Central Quay, Glasgow, Scotland, UK.
| | - Mairi Albiston
- NHS Education for Scotland, 2 Central Quay, Glasgow, Scotland, UK
| | - Martin Dunbar
- Stobhill Hospital, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Alan Gillies
- NHS Education for Scotland, 2 Central Quay, Glasgow, Scotland, UK
| | | | - Helen Moffat
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
| | - Judy Thomson
- NHS Education for Scotland, 2 Central Quay, Glasgow, Scotland, UK
| |
Collapse
|
9
|
Lanini I, Amass T, Calabrisotto CS, Fabbri S, Falsini S, Adembri C, Di Filippo A, Romagnoli S, Villa G. The influence of psychological interventions on surgical outcomes: a systematic review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:31. [PMID: 37386591 DOI: 10.1186/s44158-022-00057-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 06/10/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND An amplified and/or prolonged surgical stress response might overcome the organs' functional reserve, thus leading to postoperative complications. The aim of this systematic literature review is to underline how specific psychological interventions may contribute to improve surgical outcomes through the positive modulation of the surgical stress response in surgical patients. METHODS We conducted a comprehensive literature search in the Cochrane Register of Controlled Trials, PubMed, EMBASE, Scopus, PsycINFO, and CINAHL databases. Only studies published in English from Jan 2000 to Apr 2022 and reporting pain and/or anxiety among outcome measures were included in the review. The following psychological interventions were considered: (1) relaxation techniques, (2) cognitive-behavioral therapies, (3) mindfulness, (4) narrative medicine, (5) hypnosis, and (6) coping strategies. RESULTS Among 3167 records identified in the literature, 5 papers were considered eligible for inclusion in this review because reporting the effects that psychological features have on neurochemical signaling during perioperative metabolic adaptation and those metabolic and clinical effects that the psychological interventions had on the observed population. CONCLUSION Our findings confirm that psychological interventions may contribute to improve surgical outcomes via the positive influence on patients' metabolic surgical stress response. A multidisciplinary approach integrating physical and non-physical therapies can be considered a good strategy to successfully improve surgical outcomes in the perioperative period.
Collapse
Affiliation(s)
- Iacopo Lanini
- Department of Health Sciences, Section of Anesthesiology, and Intensive Care, University of Florence, Florence, Italy
| | - Timothy Amass
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO, USA
| | - Caterina Scirè Calabrisotto
- Department of Health Sciences, Section of Anesthesiology, and Intensive Care, University of Florence, Florence, Italy
| | - Sergio Fabbri
- Department of Health Sciences, Section of Anesthesiology, and Intensive Care, University of Florence, Florence, Italy.
| | - Silvia Falsini
- Department of Health Sciences, Section of Anesthesiology, and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Chiara Adembri
- Department of Health Sciences, Section of Anesthesiology, and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Alessandro Di Filippo
- Department of Health Sciences, Section of Anesthesiology, and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Stefano Romagnoli
- Department of Health Sciences, Section of Anesthesiology, and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Gianluca Villa
- Department of Health Sciences, Section of Anesthesiology, and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| |
Collapse
|
10
|
Peat G, Jordan KP, Wilkie R, Corp N, van der Windt DA, Yu D, Narle G, Ali N. Do recommended interventions widen or narrow inequalities in musculoskeletal health? An equity-focussed systematic review of differential effectiveness. J Public Health (Oxf) 2022; 44:e376-e387. [PMID: 35257184 PMCID: PMC9424108 DOI: 10.1093/pubmed/fdac014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 05/10/2021] [Indexed: 11/15/2022] Open
Abstract
Background It is unclear whether seven interventions recommended by Public Health England for preventing and managing common musculoskeletal conditions reduce or widen health inequalities in adults with musculoskeletal conditions. Methods We used citation searches of Web of Science (date of ‘parent publication’ for each intervention to April 2021) to identify original research articles reporting subgroup or moderator analyses of intervention effects by social stratifiers defined using the PROGRESS-Plus frameworks. Randomized controlled trials, controlled before-after studies, interrupted time series, systematic reviews presenting subgroup/stratified analyses or meta-regressions, individual participant data meta-analyses and modelling studies were eligible. Two reviewers independently assessed the credibility of effect moderation claims using Instrument to assess the Credibility of Effect Moderation Analyses. A narrative approach to synthesis was used (PROSPERO registration number: CRD42019140018). Results Of 1480 potentially relevant studies, seven eligible analyses of single trials and five meta-analyses were included. Among these, we found eight claims of potential differential effectiveness according to social characteristics, but none that were judged to have high credibility. Conclusions In the absence of highly credible evidence of differential effectiveness in different social groups, and given ongoing national implementation, equity concerns may be best served by investing in monitoring and action aimed at ensuring fair access to these interventions.
Collapse
Affiliation(s)
- G Peat
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - K P Jordan
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - R Wilkie
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - N Corp
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - D A van der Windt
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - D Yu
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - G Narle
- Public Health England, London, SE1 8UG, UK.,Versus Arthritis, Chesterfield, S41 7TD, UK
| | - N Ali
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, SW1H 0EU, UK
| |
Collapse
|
11
|
Deegan O, Fullen BM, Casey MB, Segurado R, Hearty C, Doody CM. Combined online interactive mindfulness and exercise programme (MOVE-Online) compared with a self-management guide for adults with chronic pain: protocol for a randomised controlled feasibility trial. BMJ Open 2022; 12:e058265. [PMID: 35140163 PMCID: PMC8830222 DOI: 10.1136/bmjopen-2021-058265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Online pain management programmes (PMP) have growing evidence as effective interventions for individuals with chronic pain (CP). Mindfulness-based stress reduction (MBSR) is a psychological intervention proven to be effective in the management of CP. There is also a large body of evidence for the efficacy of exercise in the management of CP however, there are limited studies combining both these interventions and none to date delivering a combined intervention in the form of an online PMP. This study aims to explore the acceptability and feasibility of delivering a combined MBSR and exercise online PMP for adults with CP, and will examine the feasibility of conducting a randomised controlled trial of a combined MBSR and exercise online programme compared with an online self-management guide. METHODS AND ANALYSIS A parallel-group, feasibility randomised controlled trial (RCT) will be conducted among participants in Ireland, which will include an embedded qualitative study. Seventy-five participants will complete an online consent form and be individually randomised to one of two groups. Group A will participate in live online MBSR and supervised exercise sessions (2 hours MBSR, 1 hour exercise) once a week for 8 weeks. Group B will receive access to an 8-week online self-management guide, released biweekly and containing eight self-directed modules. Analyses of the feasibility study will be descriptive and will address the outcomes relating to the feasibility and acceptability of the interventions and procedures of the study including recruitment and eligibility, data collection methods, intervention adherence, engagement and attrition rates, intervention acceptability and participants' subjective perceptions of the programmes. Comparisons of clinical treatment effects, using validated patient-reported outcome measures will be explored descriptively to consider the viability of investigating a combined online MBSR and exercise intervention in a future fully powered RCT. ETHICS AND DISSEMINATION This study was approved by the Mater Misericordiae University Hospital Institutional Review Board (1/378/2124) and the University College Dublin Human Research Ethics Committee (LS-20-76-Deegan-Doody). Informed consent will be obtained from each participant prior to randomisation. The results of this feasibility study will be published in peer-reviewed academic journals and presented at national and international conferences. TRIAL REGISTRATION NCT04899622.
Collapse
Affiliation(s)
- Orla Deegan
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Brona M Fullen
- School of Public Health Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Maire-Brid Casey
- School of Public Health Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Ricardo Segurado
- CSTAR, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Conor Hearty
- Department of Pain Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Catherine M Doody
- School of Public Health Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| |
Collapse
|
12
|
Verhagen A, Stubbs PW, Mehta P, Kennedy D, Nasser AM, Quel de Oliveira C, Pate JW, Skinner IW, McCambridge AB. Comparison between 2000 and 2018 on the reporting of statistical significance and clinical relevance in physiotherapy clinical trials in six major physiotherapy journals: a meta-research design. BMJ Open 2022; 12:e054875. [PMID: 34980625 PMCID: PMC8724707 DOI: 10.1136/bmjopen-2021-054875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
DESIGN Meta-research. OBJECTIVE To compare the prevalence of reporting p values, effect estimates and clinical relevance in physiotherapy randomised controlled trials (RCTs) published in the years 2000 and 2018. METHODS We performed a meta-research study of physiotherapy RCTs obtained from six major physiotherapy peer-reviewed journals that were published in the years 2000 and 2018. We searched the databases Embase, Medline and PubMed in May 2019, and extracted data on the study characteristics and whether articles reported on statistical significance, effect estimates and confidence intervals for baseline, between-group, and within-group differences, and clinical relevance. Data were presented using descriptive statistics and inferences were made based on proportions. A 20% difference between 2000 and 2018 was regarded as a meaningful difference. RESULTS We found 140 RCTs: 39 were published in 2000 and 101 in 2018. Overall, there was a high prevalence (>90%) of reporting p values for the main (between-group) analysis, with no difference between years. Statistical significance testing was frequently used for evaluating baseline differences, increasing from 28% in 2000 to 61.4% in 2018. The prevalence of reporting effect estimates, CIs and the mention of clinical relevance increased from 2000 to 2018 by 26.6%, 34% and 32.8% respectively. Despite an increase in use in 2018, over 40% of RCTs failed to report effect estimates, CIs and clinical relevance of results. CONCLUSION The prevalence of using p values remains high in physiotherapy research. Although the proportion of reporting effect estimates, CIs and clinical relevance is higher in 2018 compared to 2000, many publications still fail to report and interpret study findings in this way.
Collapse
Affiliation(s)
- Arianne Verhagen
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Peter William Stubbs
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Poonam Mehta
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - David Kennedy
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Anthony M Nasser
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Camila Quel de Oliveira
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Joshua W Pate
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Ian W Skinner
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- School of Allied Health, Department Exercise and Sports Sciences, Charles Sturt University, Port Macquarie, New South Wales, Australia
| | - Alana B McCambridge
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
13
|
Chowdhury AR, Graham PL, Schofield D, Cunich M, Nicholas M. Cost-effectiveness of Multidisciplinary Interventions for Chronic Low Back Pain: A Narrative Review. Clin J Pain 2021; 38:197-207. [PMID: 34812772 PMCID: PMC8823904 DOI: 10.1097/ajp.0000000000001009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Chronic musculoskeletal pain in adults is a global health and economic problem. The aim of this paper was to systematically review and determine what proportion of multidisciplinary approaches to managing chronic musculoskeletal pain are cost-effective. MATERIALS AND METHODS The EconLit, Embase, and PubMed electronic databases were searched for randomized and nonrandomized economic evaluation studies of nonpharmaceutical multidisciplinary chronic pain management interventions published from inception through to August 2019. RESULTS Seven studies comprising 2095 patients were included. All studies involved diverse multidisciplinary teams in one or more of the study arms. All studies involved chronic (both chronic and subacute) low back pain and were economic evaluations from either a societal or health care perspective. Two of the 3 studies that reported on a multidisciplinary pain intervention compared with nonmultidisciplinary intervention concluded favorable cost-effectiveness based on cost per quality adjusted life years gained, 1 study was not found to be cost-effective. Cost-effectiveness of the multidisciplinary intervention of interest was also not established by another 3-arm study. Two studies compared 2 multidisciplinary interventions; neither of these could definitively declare cost-effectiveness. The remaining study indicated the intervention by a multidisciplinary team was more effective but at a higher cost. None of the included studies used decision models to estimate long-term health outcomes and cost-effectiveness of multidisciplinary programs. DISCUSSION There are few studies on the cost-effectiveness of multidisciplinary chronic pain management interventions. This study encourages additional rigorous economic evaluations of multidisciplinary models for chronic pain management. Economic evaluations that enable extrapolating costs and effects of multidisciplinary programs beyond the time horizon of clinical trials may be more informative for clinicians and health administrators.
Collapse
Affiliation(s)
| | - Petra L. Graham
- Department of Mathematics and Statistics, Macquarie University
| | - Deborah Schofield
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie Business School, Macquarie University, Sydney
| | - Michelle Cunich
- Charles Perkins Centre, Faculty of Medicine and Health (Central Clinical School), The University of Sydney
- Sydney Institute for Women, Children and their Families, Sydney Local Health District
- Sydney Health Economics Collaborative, Sydney Local Health District, Camperdown, NSW, Australia
| | | |
Collapse
|
14
|
Martinson A, Craner J, Clinton-Lont J. Outcomes of a 6-week Cognitive-Behavioral Therapy for Chronic Pain Group for veterans seen in primary care. Transl Behav Med 2021; 10:254-266. [PMID: 30561740 DOI: 10.1093/tbm/iby127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Primary Care Mental Health Integration (PC-MHI) visits are mandated to be brief, limited in number, and delivered in the primary care practice area. Current evidence-based protocols for Cognitive-Behavioral Therapy for Chronic Pain (CBT-CP) do not meet these PC-MHI requirements, however, and thus PC-MHI providers are often left with the daunting task of modifying these protocols for the primary care setting. The aims of the current study were to examine effectiveness for a brief CBT-CP Group (6, 50-min sessions) for patients seen in primary care with various chronic pain conditions and to assess whether opioid medication use was associated with treatment outcomes. The current study represents a single-arm treatment study in which outcomes were evaluated by comparing self-reported symptom levels at the beginning of treatment (Session 1) to the end of treatment (Session 6). Dependent variables included pain symptoms, physical function lower/upper body, family disability, emotional functioning, sleep problems, satisfactions with outcomes/care, pain-related anxiety, generalized anxiety, pain catastrophizing, and depressed mood. Seventy-seven participants were enrolled and completed the treatment group. They were 56.81 ± 13.11 years old, 61% male, 51.9% taking opioids, with 39% reporting multiple pain diagnoses. Results showed that participation in the Brief CBT-CP Group resulted in statistically significantly improvement across all dependent variables (except emotional functioning). Results also showed that there were no significant treatment-related differences between patients taking opioids compared with patients who were not on opioids. The current protocol for Brief CBT-CP is effective in a real-world setting and aligns with the PC-MHI model of care.
Collapse
Affiliation(s)
- Amber Martinson
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Julia Craner
- The Pain Center, Mary Free Bed Rehabilitation Hospital, Suite, Grand Rapids, MI, USA.,College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | | |
Collapse
|
15
|
Ooms A, Dutton SJ, Parsons S, Fordham B, Hing C, Lamb S, Smith T. Statistical analysis plan for a pragmatic phase III randomised controlled trial examining behaviour change physiotherapy intervention to increase physical activity following hip and knee replacements: the PEP-TALK trial. Trials 2021; 22:467. [PMID: 34284802 PMCID: PMC8290138 DOI: 10.1186/s13063-021-05362-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total hip (THR) and total knee replacements (TKR) are two highly successful orthopaedic procedures that reduce pain for people with osteoarthritis. Previous evidence suggests that physical activity, at best, remains the same pre- to post-operatively, and in some instances declines. The PEP-TALK trial evaluates the effects of a group-based, behaviour change intervention on physical activity following a THR or TKR. METHODS PEP-TALK is an open, phase III, pragmatic, multi-centre, parallel, two-arm, two-way superiority randomised controlled trial investigating the effectiveness of usual care plus a behaviour change therapy compared with usual care alone following primary THR or TKR. The primary outcome is the UCLA Activity Score at 12 months post-randomisation which will be analysed using a linear mixed effects model. Secondary outcomes measured at 6 months and 12 months after randomisation include the UCLA Activity Score, Lower Extremity Functional Scale, Oxford Hip/Knee Score, Numerical Rating Scale for Pain, Generalised Self-Efficacy Scale, Tampa Scale for Kinesiophobia, Hospital Anxiety and Depression Scale, EuroQoL EQ-5D-5L index and EQ-VAS and complications or adverse events. Full details of the planned analysis approaches for the primary and secondary outcomes, as well as the planned sensitivity analyses to be undertaken due to the COVID-19 pandemic, are described here. The PEP-TALK study protocol has been published previously. DISCUSSION This paper provides details of the planned statistical analyses for the PEP-TALK trial. This is aimed to reduce the risk of outcome reporting bias and enhance transparency in reporting. TRIAL REGISTRATION International Standard Randomised Controlled Trials database, ISRCTN Number: 29770908 . Registered on October 2018.
Collapse
Affiliation(s)
- Alexander Ooms
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Scott Parsons
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Beth Fordham
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Caroline Hing
- University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
| | - Sarah Lamb
- College of Medicine and Health Sciences, University of Exeter, Exeter, Devon, UK
| | - Toby Smith
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| |
Collapse
|
16
|
Gallyer V, Smith TO, Fordham B, Dutton S, Chester-Jones M, Lamb SE, Winter SC. Getting Recovery Right After Neck Dissection (GRRAND-F): mixed-methods feasibility study to design a pragmatic randomised controlled trial protocol. BMJ Open 2021; 11:e045741. [PMID: 34155073 PMCID: PMC8217923 DOI: 10.1136/bmjopen-2020-045741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION We will evaluate the feasibility of a randomised controlled trial to estimate the effectiveness and cost-effectiveness of a rehabilitation intervention on pain, function and health-related quality of life following neck dissection (ND) after head and neck cancer (HNC). METHODS AND ANALYSIS This is a pragmatic, multicentred, feasibility study. Participants are randomised to usual care (control) or usual care plus an individualised, rehabilitation programme (Getting Recovery Right After Neck Dissection, GRRAND intervention). Adults aged over 18 with HNC for whom ND is part of their care will be recruited from specialist clinics. Participants are randomised in 1:1 ratio using a web-based service. The target sample size is 60 participants. Usual care will be received by all participants during their postoperative inpatient stay consisting standard National Health Service care supplemented with a booklet advising on postoperative self-management strategies. The GRRAND intervention programme consists of usual care plus up to six individual physiotherapy sessions including neck and shoulder range of motion (ROM) and progressive resistance exercises, advice and education. Between sessions participants will be advised to complete a home exercise programme. The primary outcome is to determine recruitment and retention rates from study participants across sites. Outcomes will be measured at 6 and 12 months. Participants and physiotherapists will be invited to an optional qualitative interview at the completion of their involvement in the study. The target qualitative sample size is 15 participants and 12 physiotherapists. Interviews aim to further investigate the feasibility and acceptability of the intervention and to determine wider experiences of the study design and intervention from patient and physiotherapist perspectives. ETHICS AND DISSEMINATION Ethical approval was given on 29 October 2019 (National Research Ethics Committee Number: 19/SC/0457). Results will be reported at conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER ISRCTN11979997. STATUS Trial recruitment is ongoing and is expected to be completed by 30 August 2021.
Collapse
Affiliation(s)
- Victoria Gallyer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
| | - Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Beth Fordham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
| | - Susan Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Mae Chester-Jones
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Stuart C Winter
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, Oxfordshire, UK
| |
Collapse
|
17
|
Bruce J, Hossain A, Lall R, Withers EJ, Finnegan S, Underwood M, Ji C, Bojke C, Longo R, Hulme C, Hennings S, Sheridan R, Westacott K, Ralhan S, Martin F, Davison J, Shaw F, Skelton DA, Treml J, Willett K, Lamb SE. Fall prevention interventions in primary care to reduce fractures and falls in people aged 70 years and over: the PreFIT three-arm cluster RCT. Health Technol Assess 2021; 25:1-114. [PMID: 34075875 DOI: 10.3310/hta25340] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Falls and fractures are a major problem. OBJECTIVES To investigate the clinical effectiveness and cost-effectiveness of alternative falls prevention interventions. DESIGN Three-arm, pragmatic, cluster randomised controlled trial with parallel economic analysis. The unit of randomisation was the general practice. SETTING Primary care. PARTICIPANTS People aged ≥ 70 years. INTERVENTIONS All practices posted an advice leaflet to each participant. Practices randomised to active intervention arms (exercise and multifactorial falls prevention) screened participants for falls risk using a postal questionnaire. Active treatments were delivered to participants at higher risk of falling. MAIN OUTCOME MEASURES The primary outcome was fracture rate over 18 months, captured from Hospital Episode Statistics, general practice records and self-report. Secondary outcomes were falls rate, health-related quality of life, mortality, frailty and health service resource use. Economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit. RESULTS Between 2011 and 2014, we randomised 63 general practices (9803 participants): 21 practices (3223 participants) to advice only, 21 practices (3279 participants) to exercise and 21 practices (3301 participants) to multifactorial falls prevention. In the active intervention arms, 5779 out of 6580 (87.8%) participants responded to the postal fall risk screener, of whom 2153 (37.3%) were classed as being at higher risk of falling and invited for treatment. The rate of intervention uptake was 65% (697 out of 1079) in the exercise arm and 71% (762 out of 1074) in the multifactorial falls prevention arm. Overall, 379 out of 9803 (3.9%) participants sustained a fracture. There was no difference in the fracture rate between the advice and exercise arms (rate ratio 1.20, 95% confidence interval 0.91 to 1.59) or between the advice and multifactorial falls prevention arms (rate ratio 1.30, 95% confidence interval 0.99 to 1.71). There was no difference in falls rate over 18 months (exercise arm: rate ratio 0.99, 95% confidence interval 0.86 to 1.14; multifactorial falls prevention arm: rate ratio 1.13, 95% confidence interval 0.98 to 1.30). A lower rate of falls was observed in the exercise arm at 8 months (rate ratio 0.78, 95% confidence interval 0.64 to 0.96), but not at other time points. There were 289 (2.9%) deaths, with no differences by treatment arm. There was no evidence of effects in prespecified subgroup comparisons, nor in nested intention-to-treat analyses that considered only those at higher risk of falling. Exercise provided the highest expected quality-adjusted life-years (1.120), followed by advice and multifactorial falls prevention, with 1.106 and 1.114 quality-adjusted life-years, respectively. NHS costs associated with exercise (£3720) were lower than the costs of advice (£3737) or of multifactorial falls prevention (£3941). Although incremental differences between treatment arms were small, exercise dominated advice, which in turn dominated multifactorial falls prevention. The incremental net monetary benefit of exercise relative to treatment valued at £30,000 per quality-adjusted life-year is modest, at £191, and for multifactorial falls prevention is £613. Exercise is the most cost-effective treatment. No serious adverse events were reported. LIMITATIONS The rate of fractures was lower than anticipated. CONCLUSIONS Screen-and-treat falls prevention strategies in primary care did not reduce fractures. Exercise resulted in a short-term reduction in falls and was cost-effective. FUTURE WORK Exercise is the most promising intervention for primary care. Work is needed to ensure adequate uptake and sustained effects. TRIAL REGISTRATION Current Controlled Trials ISRCTN71002650. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 34. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Anower Hossain
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK.,Institute of Statistical Research and Training, University of Dhaka, Dhaka, Bangladesh
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Emma J Withers
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Susanne Finnegan
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Chris Bojke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Roberta Longo
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Susie Hennings
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Ray Sheridan
- General Medicine/Care of the Elderly, Royal Devon and Exeter Hospital, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Katharine Westacott
- Elderly Care Department, Warwick Hospital, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Shvaita Ralhan
- Gerontology Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Finbarr Martin
- St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John Davison
- Falls and Syncope Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Fiona Shaw
- Falls and Syncope Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dawn A Skelton
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Jonathan Treml
- Geriatric Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith Willett
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK.,College of Medicine and Health, University of Exeter, Exeter, UK.,Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
18
|
Abbey H, Nanke L, Brownhill K. Developing a psychologically-informed pain management course for use in osteopathic practice: The OsteoMAP cohort study. INT J OSTEOPATH MED 2021. [DOI: 10.1016/j.ijosm.2020.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
19
|
O'Leary S, Raymer M, Window P, Swete Kelly P, Lee D, Garsden L, Tweedy R, Phillips B, O'Sullivan W, Wake A, Smith A, Pahor S, Pearce L, McLean R, Thompson D, Williams E, Nolan D, Anning J, Seels I, Wickins D, Marks D, Diplock B, Parravicini V, Parnwell L, Vicenzino B, Comans T, Cottrell M, Khan A, McPhail S. A multisite longitudinal evaluation of patient characteristics associated with a poor response to non-surgical multidisciplinary management of low back pain in an advanced practice physiotherapist-led tertiary service. BMC Musculoskelet Disord 2020; 21:807. [PMID: 33272228 PMCID: PMC7713165 DOI: 10.1186/s12891-020-03839-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 11/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-surgical multidisciplinary management is often the first pathway of care for patients with chronic low back pain (LBP). This study explores if patient characteristics recorded at the initial service examination have an association with a poor response to this pathway of care in an advanced practice physiotherapist-led tertiary service. METHODS Two hundred and forty nine patients undergoing non-surgical multidisciplinary management for their LBP across 8 tertiary public hospitals in Queensland, Australia participated in this prospective longitudinal study. Generalised linear models (logistic family) examined the relationship between patient characteristics and a poor response at 6 months follow-up using a Global Rating of Change measure. RESULTS Overall 79 of the 178 (44%) patients completing the Global Rating of Change measure (28.5% loss to follow-up) reported a poor outcome. Patient characteristics retained in the final model associated with a poor response included lower Formal Education Level (ie did not complete school) (Odds Ratio (OR (95% confidence interval)) (2.67 (1.17-6.09), p = 0.02) and higher self-reported back disability (measured with the Oswestry Disability Index) (OR 1.33 (1.01-1.77) per 10/100 point score increase, p = 0.046). CONCLUSIONS A low level of formal education and high level of self-reported back disability may be associated with a poor response to non-surgical multidisciplinary management of LBP in tertiary care. Patients with these characteristics may need greater assistance with regard to their comprehension of health information, and judicious monitoring of their response to facilitate timely alternative care if no benefits are attained.
Collapse
Affiliation(s)
- Shaun O'Leary
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia. .,Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Maree Raymer
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Peter Window
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Patrick Swete Kelly
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Darryl Lee
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Linda Garsden
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Rebecca Tweedy
- Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Ben Phillips
- Physiotherapy Department, Townsville Hospital, Townsville, Australia
| | - Will O'Sullivan
- Physiotherapy Department, Townsville Hospital, Townsville, Australia
| | - Anneke Wake
- Physiotherapy Department, Townsville Hospital, Townsville, Australia
| | - Alison Smith
- Physiotherapy Department, Cairns Hospital, Cairns, Australia
| | - Sheryl Pahor
- Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Luen Pearce
- Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Rod McLean
- Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - David Thompson
- Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Erica Williams
- Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Damien Nolan
- Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Jody Anning
- Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Ian Seels
- Physiotherapy Department, Nambour Hospital, Nambour, Australia
| | - Daniel Wickins
- Physiotherapy Department, Redcliffe Hospital, Redcliffe, Australia
| | - Darryn Marks
- Physiotherapy Department, Gold Coast Hospital, Gold Coast, Australia.,Physiotherapy, Faculty of Health Sciences & Medicine, Bond Institute of Health and Sport, Bond University, Robina, Australia
| | | | | | - Linda Parnwell
- Physiotherapy Department, Logan Hospital, Logan, Australia
| | - Bill Vicenzino
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
| | - Tracy Comans
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
| | - Michelle Cottrell
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia.,Physiotherapy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Asaduzzaman Khan
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
| | - Steven McPhail
- Clinical Informatics Directorate, Metro South Hospital and Health Service, Brisbane, Australia.,Australian Centre for Health Services Innovation & Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Australia
| |
Collapse
|
20
|
Update of Markov Model on the Cost-effectiveness of Nonpharmacologic Interventions for Chronic Low Back Pain Compared to Usual Care. Spine (Phila Pa 1976) 2020; 45:1383-1385. [PMID: 32516169 PMCID: PMC7751339 DOI: 10.1097/brs.0000000000003539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Markov model. OBJECTIVE Further validity test of a previously published model. SUMMARY OF BACKGROUND DATA The previous model was built using data from ten randomized trials and examined the 1-year effectiveness and cost-effectiveness of 17 nonpharmacologic interventions for chronic low back pain (CLBP), each compared to usual care alone. This update incorporated data from five additional trials. METHODS Based on transition probabilities that were estimated using patient-level trial data, a hypothetical cohort of CLBP patients transitioned over time among four defined health states: high-impact chronic pain with substantial activity limitations; higher (moderate-impact) and lower (low-impact) pain without activity limitations; and no pain. As patients transitioned among health states, they accumulated quality-adjusted life-years, as well as healthcare and productivity costs. Costs and effects were calculated incremental to each study's version of usual care. RESULTS From the societal perspective and assuming a typical patient mix (25% low-impact, 35% moderate-impact, and 40% high-impact chronic pain), most interventions-including those newly added-were cost-effective (<$50,000/QALY) and demonstrated cost savings. From the payer perspective, fewer were cost-saving, but the same number were cost-effective. Results for the new studies generally mirrored others using the same interventions-for example, cognitive behavioral therapy (CBT) and physical therapy. A new acupuncture study had similar effectiveness to other acupuncture studies, but higher usual care costs, resulting in higher cost savings. Two new yoga studies' results were similar, but both differed from those of the original yoga study. Mindfulness-based stress reduction was similar to CBT for a typical patient mix but was twice as effective for those with high-impact chronic pain. CONCLUSION Markov modeling facilitates comparisons across interventions not directly compared in trials, using consistent outcome measures after balancing the baseline mix of patients. Outcomes also differed by pain impact level, emphasizing the need to measure CLBP subgroups. LEVEL OF EVIDENCE N/A.
Collapse
|
21
|
Sanchez Santos MT, Williamson E, Bruce J, Ward L, Mallen CD, Garrett A, Morris A, Lamb SE. Cohort profile: Oxford Pain, Activity and Lifestyle (OPAL) Study, a prospective cohort study of older adults in England. BMJ Open 2020; 10:e037516. [PMID: 32883729 PMCID: PMC7473632 DOI: 10.1136/bmjopen-2020-037516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The 'Oxford Pain, Activity and Lifestyle' (OPAL) Cohort is a longitudinal, prospective cohort study of adults, aged 65 years and older, living in the community which is investigating the determinants of health in later life. Our focus was on musculoskeletal pain and mobility, but the cohort is designed with flexibility to include new elements over time. This paper describes the study design, data collection and baseline characteristics of participants. We also compared the OPAL baseline characteristics with nationally representative data sources. PARTICIPANTS We randomly selected eligible participants from two stratified age bands (65-74 and 75 and over years). In total, 5409 individuals (42.1% of eligible participants) from 35 general practices in England agreed to participate between 2016 and 2018. The majority of participants (n=5367) also consented for research team to access their UK National Health Service (NHS) Digital and primary healthcare records. FINDINGS TO DATE Mean participant age was 74.9 years (range 65-100); 51.5% (n=2784/5409) were women. 94.9% of participants were white, and 28.8% lived alone. Over 83.0% reported pain in at least one body area in the previous 6 weeks. Musculoskeletal symptoms were more prevalent in women (86.4%). One-third of participants reported having one or more falls in the last year. Most participants were confident in their ability to walk outside. The characteristics of OPAL Cohort participants were broadly similar to the general population of the same age. FUTURE PLANS Postal follow-up of the cohort is being undertaken at annual intervals, with data collection ongoing. Linkage to NHS hospital admission data is planned. This English prospective cohort offers a large and rich resource for research on the longitudinal associations between demographic, clinical, and social factors and health trajectories and outcomes in community-dwelling older people.
Collapse
Affiliation(s)
- Maria T Sanchez Santos
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Esther Williamson
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciencies, University of Warwick, Coventry, UK
| | - Lesley Ward
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Sport, Exercise & Rehabilitation, Northumbria University, Newcastle-Upon-Tyne, UK
| | - Christian D Mallen
- Shool of Primary, Community and Social Care, Keele University, Keele, UK
| | - Angela Garrett
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alana Morris
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| |
Collapse
|
22
|
Comer C, Lee H, Williamson E, Lamb S. Understanding the mechanisms of a combined physical and psychological intervention for people with neurogenic claudication: protocol for a causal mediation analysis of the BOOST trial. BMJ Open 2020; 10:e037121. [PMID: 32878759 PMCID: PMC7470505 DOI: 10.1136/bmjopen-2020-037121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Conservative treatments such as exercise are recommended for the management of people with neurogenic claudication from spinal stenosis. However, the effectiveness and mechanisms of effect are unknown. This protocol outlines an a priori plan for a secondary analysis of a multicentre randomised controlled trial of a physiotherapist-delivered, combined physical and psychological intervention (Better Outcomes for Older people with Spinal Trouble (BOOST) programme). METHODS AND ANALYSES We will use causal mediation analysis to estimate the mechanistic effects of the BOOST programme on the primary outcome of disability (measured by the Oswestry Disability Index). The primary mechanism of interest is walking capacity, and secondary mediators include fear-avoidance behaviour, walking self-efficacy, physical function, physical activity and/or symptom severity. All mediators will be measured at 6 months and the outcome will be measured at 12 months from randomisation. Patient characteristics and possible confounders of the mediator-outcome effect will be measured at baseline. Sensitivity analyses will be conducted to evaluate the robustness of the estimated effects to varying levels of residual confounding. ETHICS AND DISSEMINATION Ethical approval was given on 3 March 2016 (National Research Ethics Committee number: 16/LO/0349). The results of this analysis will be disseminated in peer-reviewed journals and at relevant scientific conferences. TRIAL REGISTRATION NUMBER ISRCTN12698674.
Collapse
Affiliation(s)
- Christine Comer
- Musculoskeletal and Rehabilitation Services, Leeds Community Healthcare NHS Trust, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | - Hopin Lee
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
- The Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
| | - Esther Williamson
- The Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
| | - Sarah Lamb
- The Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, Oxfordshire, UK
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| |
Collapse
|
23
|
Smith TO, Parsons S, Fordham B, Ooms A, Dutton S, Hing C, Barber VS, Png ME, Lamb S. Behaviour change physiotherapy intervention to increase physical activity following hip and knee replacement (PEP-TALK): study protocol for a pragmatic randomised controlled trial. BMJ Open 2020; 10:e035014. [PMID: 32690503 PMCID: PMC7371148 DOI: 10.1136/bmjopen-2019-035014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION While total hip replacement (THR) and total knee replacement (TKR) successfully reduce pain associated with chronic joint pathology, this infrequently translates into increased physical activity. This is a challenge given that over 50% of individuals who undergo these operations are physically inactive and have medical comorbidities such as hypertension, heart disease, diabetes and depression. The impact of these diseases can be reduced with physical activity. This trial aims to investigate the effectiveness of a behaviour change physiotherapy intervention to increase physical activity compared with usual rehabilitation after THR or TKR. METHODS AND ANALYSIS The PEP-TALK trial is a multicentre, open-labelled, pragmatic randomised controlled trial. 260 adults who are scheduled to undergo a primary unilateral THR or TKR and are moderately inactive or inactive, with comorbidities, will be recruited across eight sites in England. They will be randomised post-surgery, prior to hospital discharge, to either six, 30 min weekly group-based exercise sessions (control), or the same six weekly, group-based, exercise sessions each preceded by a 30 min cognitive behaviour approach discussion group. Participants will be followed-up to 12 months by postal questionnaire. The primary outcome is the University of California, Los Angeles (UCLA) Physical Activity Score at 12 months. Secondary outcomes include: physical function, disability, health-related quality of life, kinesiophobia, perceived pain, self-efficacy and health resource utilisation. ETHICS AND DISSEMINATION Research ethics committee approval was granted by the NRES Committee South Central (Oxford B - 18/SC/0423). Dissemination of results will be through peer-reviewed, scientific journals and conference presentations. TRIAL REGISTRATION NUMBER ISRCTN29770908.
Collapse
Affiliation(s)
- Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Scott Parsons
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Beth Fordham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alexander Ooms
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Susan Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, University of Oxford, Oxford, UK
- CSM, University of Oxford, Oxford, UK
| | - Caroline Hing
- University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
| | - Vicki S Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Sarah Lamb
- College of Medicine and Health Sciences, University of Exeter, Exeter, Devon, UK
| |
Collapse
|
24
|
Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J 2020; 20:998-1024. [PMID: 32333996 DOI: 10.1016/j.spinee.2020.04.006] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN This is a guideline summary review. METHODS This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. RESULTS Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.
Collapse
Affiliation(s)
- D Scott Kreiner
- Barrow Neurological Institute, 4530 E. Muirwood Dr. Ste. 110, Phoenix, AZ 85048-7693, USA.
| | - Paul Matz
- Advantage Orthopedics and Neurosurgery, Casper, WY, USA
| | | | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Zoher Ghogawala
- Lahey Hospital and Medical Center, Burlington, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | | | - William C Watters
- Institute of Academic Medicine Houston Methodist Hospital, Houston, TX, USA
| | - Thiru M Annaswamy
- VA North Texas Health Care System, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Randall P Brewer
- River Cities Interventional Pain Specialists, Shreveport, LA, USA
| | | | - David S Cheng
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Park
- University Of Michigan, Ann Arbor, MI, USA
| | | | | | - Ravi Prasad
- University of California, Davis, Sacramento, CA, USA
| | | | - Kris E Radcliff
- Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | - Ryan A Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | | | - Yakov Vorobeychik
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amy M Yahiro
- North American Spine Society, Burr Ridge, IL, USA
| |
Collapse
|
25
|
Froud R, Grant M, Burton K, Foss J, Ellard DR, Seers K, Smith D, Barillec M, Patel S, Haywood K, Underwood M. Development and feasibility of an intervention featuring individual supported work placements to aid return to work for unemployed people living with chronic pain. Pilot Feasibility Stud 2020; 6:49. [PMID: 32337065 PMCID: PMC7175501 DOI: 10.1186/s40814-020-00581-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 03/10/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Working in good jobs is associated with good health. High unemployment rates are reported in those disabled with musculoskeletal pain. Supported employment interventions work well for helping people with mental health difficulties to gain and retain employment. With adaptation, these may be useful for people with chronic pain. We aimed to develop and explore the feasibility of delivering such an adapted intervention. METHODS We developed an intervention and recruited unemployed people with chronic pain from NHS pain clinics and employment services. We trained case managers to assess participants and match them to six-week work placements in the Midlands and provide ongoing support to them and their managers. Participants attended a two-day work preparation session prior to placement. Outcome measures included quality of life at baseline, six- weeks, 14-weeks, and six-months, and return to work at 14-weeks and six-months. We held focus groups or interviews with stakeholders to examine acceptability and experiences of the intervention. RESULTS We developed an intervention consisting of work preparation sessions, work experience placements, and individualised employment support. We enrolled 31 people; 27 attended work preparation sessions, and 15 attended placements. Four of our participants started jobs during the study period. We are aware of two others starting jobs shortly after cessation of follow-up. We experienced challenges to recruitment in one area where we had many and diverse placement opportunities and good recruitment in another area where we had a smaller range of placement opportunities. All stakeholders found the intervention acceptable, and it was valued by those given a placement. While there was some disappointment among those not placed, this group still valued the work preparation sessions. CONCLUSIONS The developed intervention was acceptable to participants and partners. Trialling the developed intervention could be feasible with attention to three main processes. To ensure advanced availability of a sufficiently wide range of work placements in each area, multiple partners would be needed. Multiple recruitment sites and focus on employment services will yield better recruitment rates than reliance on NHS pain clinics. Maintaining an adequate follow-up response rate will likely require additional approaches with more than the usual effort.
Collapse
Affiliation(s)
- Robert Froud
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
- Institute of Health Sciences, Kristiania University College, Prinsens Gate 7-9, 0152 Oslo, Norway
| | - Mary Grant
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Kim Burton
- Centre for Applied Research in Health, School of Human & Health Sciences, The University of Huddersfield, Queensgate, Huddersfield, HD1 3DH UK
| | - Jonathan Foss
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - David R. Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Kate Seers
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Deb Smith
- University/User Teaching and Research Action Partnership, University of Warwick, Coventry, UK
| | - Mariana Barillec
- Serco UK & Europe; Employment, Skills and Enterprise, Trigate Business Centre, 210-222 Hagley Road West, Birmingham, B68 0NP UK
| | - Shilpa Patel
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Kirstie Haywood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| |
Collapse
|
26
|
Hill JC, Garvin S, Chen Y, Cooper V, Wathall S, Saunders B, Lewis M, Protheroe J, Chudyk A, Dunn KM, Hay E, van der Windt D, Mallen C, Foster NE. Stratified primary care versus non-stratified care for musculoskeletal pain: findings from the STarT MSK feasibility and pilot cluster randomized controlled trial. BMC FAMILY PRACTICE 2020; 21:30. [PMID: 32046647 PMCID: PMC7014664 DOI: 10.1186/s12875-019-1074-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/23/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Musculoskeletal (MSK) pain from the five most common presentations to primary care (back, neck, shoulder, knee or multi-site pain), where the majority of patients are managed, is a costly global health challenge. At present, first-line decision-making is based on clinical reasoning and stratified models of care have only been tested in patients with low back pain. We therefore, examined the feasibility of; a) a future definitive cluster randomised controlled trial (RCT), and b) General Practitioners (GPs) providing stratified care at the point-of-consultation for these five most common MSK pain presentations. METHODS The design was a pragmatic pilot, two parallel-arm (stratified versus non-stratified care), cluster RCT and the setting was 8 UK GP practices (4 intervention, 4 control) with randomisation (stratified by practice size) and blinding of trial statistician and outcome data-collectors. Participants were adult consulters with MSK pain without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records were tagged and individuals sent postal invitations using a GP point-of-consultation electronic medical record (EMR) template. The intervention was supported by the EMR template housing the Keele STarT MSK Tool (to stratify into low, medium and high-risk prognostic subgroups of persistent pain and disability) and recommended matched treatment options. Feasibility outcomes included exploration of recruitment and follow-up rates, selection bias, and GP intervention fidelity. To capture recommended outcomes including pain and function, participants completed an initial questionnaire, brief monthly questionnaire (postal or SMS), and 6-month follow-up questionnaire. An anonymised EMR audit described GP decision-making. RESULTS GPs screened 3063 patients (intervention = 1591, control = 1472), completed the EMR template with 1237 eligible patients (intervention = 513, control = 724) and 524 participants (42%) consented to data collection (intervention = 231, control = 293). Recruitment took 28 weeks (target 12 weeks) with > 90% follow-up retention (target > 75%). We detected no selection bias of concern and no harms identified. GP stratification tool fidelity failed to achieve a-priori success criteria, whilst fidelity to the matched treatments achieved "complete success". CONCLUSIONS A future definitive cluster RCT of stratified care for MSK pain is feasible and is underway, following key amendments including a clinician-completed version of the stratification tool and refinements to recommended matched treatments. TRIAL REGISTRATION Name of the registry: ISRCTN. TRIAL REGISTRATION NUMBER 15366334. Date of registration: 06/04/2016.
Collapse
Affiliation(s)
- J C Hill
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - S Garvin
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| | - Y Chen
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| | - V Cooper
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - S Wathall
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| | - B Saunders
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - M Lewis
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| | - J Protheroe
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - A Chudyk
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - K M Dunn
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - E Hay
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - D van der Windt
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - C Mallen
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - N E Foster
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit, School for Primary, Community and Social Care, Faculty of Medicine and Health Sciences, Keele University, Newcastle, UK
| |
Collapse
|
27
|
Petrozzi MJ, Leaver A, Ferreira PH, Rubinstein SM, Jones MK, Mackey MG. Addition of MoodGYM to physical treatments for chronic low back pain: A randomized controlled trial. Chiropr Man Therap 2019; 27:54. [PMID: 31673330 PMCID: PMC6814139 DOI: 10.1186/s12998-019-0277-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/16/2019] [Indexed: 12/21/2022] Open
Abstract
Background Low back pain (LBP) is prevalent, costly and disabling. A biopsychosocial treatment approach involving physical and cognitive behavioural therapy (CBT) is recommended for those with chronic LBP. It is not known if online psychological coaching tools might have a role in the secondary prevention of LBP related disability. To assess the effectiveness of an internet-delivered psychological program (MoodGYM) in addition to standard physical treatment in patients with chronic non-specific LBP at medium risk of ongoing disability. Methods A multisite randomized controlled trial was conducted with 108 participants (aged mean 50.4 ± 13.6 years) with chronic LBP attending one of six private physiotherapy or chiropractic clinics. Disability (Roland Morris Disability Questionnaire) and self-efficacy (Patient Self-Efficacy Questionnaire), were assessed at baseline, post-treatment (8-weeks) with follow-up at six- and twelve-months. Participants were randomized into either the intervention group, MoodGYM plus physical treatments, or the control group which received physical treatments alone. Results No statistically significant between group differences were observed for either disability at post-treatment (Effect size (standardised mean difference) 95% CI) RMD - 0.06 (- 0.45,0.31), 6-months RMD 0.01 (- 0.38,0.39) and 12-months - 0.20 (- 0.62,0.17) or self-efficacy at post-treatment PSEQ 0.06 (- 0.31,0.45), 6-months 0.02 (- 0.36,0.41) and 12-months 0.21 (- 0.16,0.63). Conclusion There was no additional benefit of an internet-delivered CBT program (MoodGYM) to physical treatments in those with chronic non-specific LBP at medium risk of ongoing disability measured at post-treatment, or at 6 and 12 months. Trial registration This trial was prospectively registered with Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000269538.
Collapse
Affiliation(s)
- M. John Petrozzi
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Andrew Leaver
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Paulo H. Ferreira
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | | | - Mairwen K. Jones
- Discipline of Behavioural and Social Sciences in Health, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Martin G. Mackey
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| |
Collapse
|
28
|
Darlow B, Stanley J, Dean S, Abbott JH, Garrett S, Wilson R, Mathieson F, Dowell A. The Fear Reduction Exercised Early (FREE) approach to management of low back pain in general practice: A pragmatic cluster-randomised controlled trial. PLoS Med 2019; 16:e1002897. [PMID: 31498799 PMCID: PMC6733445 DOI: 10.1371/journal.pmed.1002897] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/05/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Effective and cost-effective primary care treatments for low back pain (LBP) are required to reduce the burden of the world's most disabling condition. This study aimed to compare the clinical effectiveness and cost-effectiveness of the Fear Reduction Exercised Early (FREE) approach to LBP (intervention) with usual general practitioner (GP) care (control). METHODS AND FINDINGS This pragmatic, cluster-randomised controlled trial with process evaluation and parallel economic evaluation was conducted in the Hutt Valley, New Zealand. Eight general practices were randomly assigned (stratified by practice size) with a 1:1 ratio to intervention (4 practices; 34 GPs) or control group (4 practices; 29 GPs). Adults presenting to these GPs with LBP as their primary complaint were recruited. GPs in the intervention practices were trained in the FREE approach, and patients presenting to these practices received care based on the FREE approach. The FREE approach restructures LBP consultations to prioritise early identification and management of barriers to recovery. GPs in control practices did not receive specific training for this study, and patients presenting to these practices received usual care. Between 23 September 2016 and 31 July 2017, 140 eligible patients presented to intervention practices (126 enrolled) and 110 eligible patients presented to control practices (100 enrolled). Patient mean age was 46.1 years (SD 14.4), and 46% were female. The duration of LBP was less than 6 weeks in 88% of patients. Primary outcome was change from baseline in patient participant Roland Morris Disability Questionnaire (RMDQ) score at 6 months. Secondary patient outcomes included pain, satisfaction, and psychosocial indices. GP outcomes included attitudes, knowledge, confidence, and GP LBP management behaviour. There was active and passive surveillance of potential harms. Patients and outcome assessors were blind to group assignment. Analysis followed intention-to-treat principles. A total of 122 (97%) patients from 32 GPs in the intervention group and 99 (99%) patients from 25 GPs in the control group were included in the primary outcome analysis. At 6 months, the groups did not significantly differ on the primary outcome (adjusted mean RMDQ score difference 0.57, 95% CI -0.64 to 1.78; p = 0.354) or secondary patient outcomes. The RMDQ difference met the predefined criterion to indicate noninferiority. One control group participant experienced an activity-related gluteal tear, with no other adverse events recorded. Intervention group GPs had improvements in attitudes, knowledge, and confidence compared with control group GPs. Intervention group GP LBP management behaviour became more guideline concordant than the control group. In cost-effectiveness, the intervention dominated control with lower costs and higher Quality-Adjusted Life Year (QALY) gains. Limitations of this study were that although adequately powered for primary outcome assessment, the study was not powered for evaluating some employment, healthcare use, and economic outcomes. It was also not possible for research nurses (responsible for patient recruitment) to be masked on group allocation for practices. CONCLUSIONS Findings from this study suggest that the FREE approach improves GP concordance with LBP guideline recommendations but does not improve patient recovery outcomes compared with usual care. The FREE approach may reduce unnecessary healthcare use and produce economic benefits. Work participation or health resource use should be considered for primary outcome assessment in future trials of undifferentiated LBP. TRIAL REGISTRATION ACTRN12616000888460.
Collapse
Affiliation(s)
- Ben Darlow
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
- * E-mail:
| | - James Stanley
- Biostatistical Group, University of Otago, Wellington, New Zealand
| | - Sarah Dean
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - J. Haxby Abbott
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Sue Garrett
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
| | - Ross Wilson
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Fiona Mathieson
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Anthony Dowell
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
| |
Collapse
|
29
|
Hall JA, Konstantinou K, Lewis M, Oppong R, Ogollah R, Jowett S. Systematic Review of Decision Analytic Modelling in Economic Evaluations of Low Back Pain and Sciatica. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:467-491. [PMID: 30941658 DOI: 10.1007/s40258-019-00471-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Low back pain (LBP) and sciatica place significant burden on individuals and healthcare systems, with societal costs alone likely to be in excess of £15 billion. Two recent systematic reviews for LBP and sciatica identified a shortage of modelling studies in both conditions. OBJECTIVES The aim of this systematic review was to document existing model-based economic evaluations for the treatment and management of both conditions; critically appraise current modelling techniques, analytical methods, data inputs, and structure, using narrative synthesis; and identify unresolved methodological problems and gaps in the literature. METHODS A systematic literature review was conducted whereby 6512 records were extracted from 11 databases, with no date limits imposed. Studies were abstracted according to a predesigned protocol, whereby they must be economic evaluations that employed an economic decision model and considered any management approach for LBP and sciatica. Study abstraction was initially performed by one reviewer who removed duplicates and screened titles to remove irrelevant studies. Overall, 133 potential studies for inclusion were then screened independently by other reviewers. Consensus was reached between reviewers regarding final inclusion. RESULTS Twenty-one publications of 20 unique models were included in the review, five of which were modelling studies in LBP and 16 in sciatica. Results revealed a poor standard of modelling in both conditions, particularly regarding modelling techniques, analytical methods, and data quality. Specific issues relate to inappropriate representation of both conditions in terms of health states, insufficient time horizons, and use of inappropriate utility values. CONCLUSION High-quality modelling studies, which reflect modelling best practice, as well as contemporary clinical understandings of both conditions, are required to enhance the economic evidence for treatments for both conditions.
Collapse
Affiliation(s)
- James A Hall
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK.
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Haywood Hospital, Midlands Partnership Foundation Trust, Staffordshire, UK
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Keele Clinical Trials Unit, Keele University, Staffordshire, UK
| | - Raymond Oppong
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Reuben Ogollah
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sue Jowett
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| |
Collapse
|
30
|
Nascimento DP, Costa LOP, Gonzalez GZ, Maher CG, Moseley AM. Abstracts of low back pain trials are poorly reported, contain spin of information and are inconsistent with the full text: An overview study. Arch Phys Med Rehabil 2019; 100:1976-1985.e18. [PMID: 31207219 DOI: 10.1016/j.apmr.2019.03.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/09/2019] [Accepted: 03/20/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate trials abstracts evaluating treatments for low back pain with regards to completeness of reporting, spin (i.e., interpretation of study results that overemphasizes the beneficial effects of the intervention), and inconsistencies in data with the full text. DATA SOURCES The search was performed on Physiotherapy Evidence Database (PEDro) in February 2016. STUDY SELECTION This is an overview study of a random sample of 200 low back pain trials published between 2010 and 2015. The languages of publication were restricted to English, Spanish and Portuguese. DATA EXTRACTION Completeness of reporting was assessed using the CONSORT for Abstracts checklist (CONSORT-A). Spin was assessed using a SPIN-checklist. Consistency between abstract and full text were assessed by applying the assessment tools to both the abstract and full text of each trial and calculating inconsistencies in the summary score (paired t test) and agreement in the classification of each item (Kappa statistics). Methodological quality was analyzed using the total PEDro score. DATA SYNTHESIS The mean number of fully reported items for abstracts using the CONSORT-A was 5.1 (SD 2.4) out of 15 points and the mean number of items with spin was 4.9 (SD 2.6) out of 7 points. Abstract and full text scores were statistically inconsistent (P=0.01). There was slight to moderate agreement between items of the CONSORT-A in the abstracts and full text (mean Kappa 0.20 SD 0.13) and fair to moderate agreement for items of the SPIN-checklist (mean Kappa 0.47 SD 0.09). CONCLUSIONS The abstracts were incomplete, with spin and inconsistent with the full text. We advise health care professionals to avoid making clinical decisions based solely upon abstracts. Journal editors, reviewers and authors are jointly responsible for improving abstracts, which could be guided by amended editorial policies.
Collapse
Affiliation(s)
- Dafne P Nascimento
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil.
| | - Leonardo O P Costa
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil
| | - Gabrielle Z Gonzalez
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil
| | - Christopher G Maher
- Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, Sydney, Australia
| | - Anne M Moseley
- Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
31
|
Fritz J, Wallin L, Söderlund A, Almqvist L, Sandborgh M. Implementation of a behavioral medicine approach in physiotherapy: impact and sustainability. Disabil Rehabil 2019; 42:3467-3474. [PMID: 30999779 DOI: 10.1080/09638288.2019.1596170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To explore the effects on and sustainability of physiotherapists' clinical behavior when using facilitation to support the implementation of a behavioral medicine approach in primary health care for patients with persistent musculoskeletal pain.Methods: A quasi-experimental pre-/post-test trial was conducted. Fifteen physiotherapists were included in the experimental group, and nine in the control group. Based on social cognitive theory and the Promoting Action on Research Implementation in Health Services framework, facilitation with multifaceted implementation methods was used during a six-month period. Clinical behaviors were investigated with a study-specific questionnaire, structured observations, self-reports and patient records. Descriptive and non-parametric statistical methods were used for analyzing differences over time and effect size.Results: A sustained increase in self-efficacy for applying the behavioral medicine approach was found. Clinical actions and verbal expressions changed significantly, and the effect size was large; however, changes were not sustained at follow-ups. The behavioral changes were mainly related to the goal setting, self-monitoring and functional behavioral analysis components. No changes in clinical behavior were found in the control group.Conclusion: Tailored multifaceted facilitation can support the implementation of a behavioral medicine approach in physiotherapy in primary health care, but more comprehensive actions targeting sustainability are needed.Implications for rehabilitationTailored multifaceted facilitation can support the implementation of an evidence based behavioral medicine approach in physiotherapy.Facilitation can be useful for increasing self-efficacy beliefs for using behavioral medicine approach in physiotherapist's clinical practice.Further research is required to establish strategies that are effective in sustaining behavioral changes.
Collapse
Affiliation(s)
- Johanna Fritz
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Lars Wallin
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.,Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Department of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anne Söderlund
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Lena Almqvist
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Maria Sandborgh
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| |
Collapse
|
32
|
Novel approach to characterising individuals with low back-related leg pain: cluster identification with latent class analysis and 12-month follow-up. Pain 2019; 159:728-738. [PMID: 29319608 PMCID: PMC6485623 DOI: 10.1097/j.pain.0000000000001147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traditionally, low back-related leg pain (LBLP) is diagnosed clinically as referred leg pain or sciatica (nerve root involvement). However, within the spectrum of LBLP we hypothesised that there may be other, unrecognised patient subgroups. This study aimed to identify clusters of LBLP patients using latent class analysis (LCA) and describe their clinical course. The study population were 609 LBLP primary care consulters. Variables from clinical assessment were included in the LCA. Characteristics of the statistically identified clusters were compared and their clinical course over one year was described. A five cluster solution was optimal. Cluster 1 (n=104) had mild leg pain severity and was considered to represent a referred leg pain group with no clinical signs suggesting nerve root involvement (sciatica). Cluster 2 (n=122), cluster 3 (n=188) and cluster 4 (n=69) had mild, moderate and severe pain and disability respectively and response to clinical assessment items suggested categories of mild, moderate and severe sciatica. Cluster 5 (n=126) had high pain and disability, longer pain duration, more comorbidities and was difficult to map to a clinical diagnosis. Most improvement for pain and disability was seen in the first four months for all clusters. At 12 months the proportion of patients reporting recovery ranged from 27% for cluster 5 to 45% for cluster 2 (mild sciatica). This is the first study that empirically shows the variability in profile and clinical course of patients with LBLP including sciatica. More homogenous groups were identified which could be considered in future clinical and research settings.
Collapse
|
33
|
Lamb SE, Mistry D, Alleyne S, Atherton N, Brown D, Copsey B, Dosanjh S, Finnegan S, Fordham B, Griffiths F, Hennings S, Khan I, Khan K, Lall R, Lyle S, Nichols V, Petrou S, Zeh P, Sheehan B. Aerobic and strength training exercise programme for cognitive impairment in people with mild to moderate dementia: the DAPA RCT. Health Technol Assess 2019; 22:1-202. [PMID: 29848412 DOI: 10.3310/hta22280] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Approximately 670,000 people in the UK have dementia. Previous literature suggests that physical exercise could slow dementia symptom progression. OBJECTIVES To estimate the clinical effectiveness and cost-effectiveness of a bespoke exercise programme, in addition to usual care, on the cognitive impairment (primary outcome), function and health-related quality of life (HRQoL) of people with mild to moderate dementia (MMD) and carer burden and HRQoL. DESIGN Intervention development, systematic review, multicentred, randomised controlled trial (RCT) with a parallel economic evaluation and qualitative study. SETTING 15 English regions. PARTICIPANTS People with MMD living in the community. INTERVENTION A 4-month moderate- to high-intensity, structured exercise programme designed specifically for people with MMD, with support to continue unsupervised physical activity thereafter. Exercises were individually prescribed and progressed, and participants were supervised in groups. The comparator was usual practice. MAIN OUTCOME MEASURES The primary outcome was the Alzheimer's Disease Assessment Scale - Cognitive Subscale (ADAS-Cog). The secondary outcomes were function [as measured using the Bristol Activities of Daily Living Scale (BADLS)], generic HRQoL [as measured using the EuroQol-5 Dimensions, three-level version (EQ-5D-3L)], dementia-related QoL [as measured using the Quality of Life in Alzheimer's Disease (QoL-AD) scale], behavioural symptoms [as measured using the Neuropsychiatric Inventory (NPI)], falls and fractures, physical fitness (as measured using the 6-minute walk test) and muscle strength. Carer outcomes were HRQoL (Quality of Life in Alzheimer's Disease) (as measured using the EQ-5D-3L) and carer burden (as measured using the Zarit Burden Interview). The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained from a NHS and Personal Social Services perspective. We measured health and social care use with the Client Services Receipt Inventory. Participants were followed up for 12 months. RESULTS Between February 2013 and June 2015, 494 participants were randomised with an intentional unequal allocation ratio: 165 to usual care and 329 to the intervention. The mean age of participants was 77 years [standard deviation (SD) 7.9 years], 39% (193/494) were female and the mean baseline ADAS-Cog score was 21.5 (SD 9.0). Participants in the intervention arm achieved high compliance rates, with 65% (214/329) attending between 75% and 100% of sessions. Outcome data were obtained for 85% (418/494) of participants at 12 months, at which point a small, statistically significant negative treatment effect was found in the primary outcome, ADAS-Cog (patient reported), with a mean difference of -1.4 [95% confidence interval (CI) -2.62 to -0.17]. There were no treatment effects for any of the other secondary outcome measures for participants or carers: for the BADLS there was a mean difference of -0.6 (95% CI -2.05 to 0.78), for the EQ-5D-3L a mean difference of -0.002 (95% CI -0.04 to 0.04), for the QoL-AD scale a mean difference of 0.7 (95% CI -0.21 to 1.65) and for the NPI a mean difference of -2.1 (95% CI -4.83 to 0.65). Four serious adverse events were reported. The exercise intervention was dominated in health economic terms. LIMITATIONS In the absence of definitive guidance and rationale, we used a mixed exercise programme. Neither intervention providers nor participants could be masked to treatment allocation. CONCLUSIONS This is a large well-conducted RCT, with good compliance to exercise and research procedures. A structured exercise programme did not produce any clinically meaningful benefit in function or HRQoL in people with dementia or on carer burden. FUTURE WORK Future work should concentrate on approaches other than exercise to influence cognitive impairment in dementia. TRIAL REGISTRATION Current Controlled Trials ISRCTN32612072. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full programme and will be published in full in Health Technology Assessment Vol. 22, No. 28. See the NIHR Journals Library website for further project information. Additional funding was provided by the Oxford NIHR Biomedical Research Centre and the Oxford NIHR Collaboration for Leadership in Applied Health Research and Care.
Collapse
Affiliation(s)
- Sarah E Lamb
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.,Centre for Rehabilitation Research In Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sharisse Alleyne
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Nicky Atherton
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Deborah Brown
- Centre for Rehabilitation Research In Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Bethan Copsey
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Centre for Rehabilitation Research In Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sukhdeep Dosanjh
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Susanne Finnegan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Beth Fordham
- Centre for Rehabilitation Research In Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Frances Griffiths
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Susie Hennings
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Iftekhar Khan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Kamran Khan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Samantha Lyle
- Centre for Rehabilitation Research In Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Vivien Nichols
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Zeh
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Bart Sheehan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
34
|
Eaves ER, Hsu CW, DeBar LL, Livingston CJ, Ocker LE, McDonald SJ, Dillon-Sumner L, Ritenbaugh C. Whole Systems Within Whole Systems: The Oregon Health Plan's Expansion of Services for Back and Neck Pain. J Altern Complement Med 2019; 25:S61-S68. [PMID: 30870022 DOI: 10.1089/acm.2018.0431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The authors employ a Whole Systems framework to explore implementation of new guidelines for back and neck pain in Oregon's Medicaid system. Whole Systems research is useful for understanding the relationship between complementary and integrative health care (CIH) and conventional health care systems in real-world clinical and practice settings. DESIGN Preliminary results are from an observational study designed to evaluate state-wide implementation of CIH and other non-pharmacological treatments for neck and back pain among Oregon Medicaid patients. This natural experiment, even in early stages, provides insight into the challenges of integrating Whole Systems oriented therapies into Medicaid billing and treatment. METHODS Qualitative data are drawn from: (1) semi-structured interviews with representatives of each of the 16 coordinated care organizations (CCOs) responsible for administering the Oregon's Medicaid insurance through the Oregon Health Plan (OHP); and (2) open-ended survey responses from acupuncturists in all 16 CCO areas. RESULTS Implementation of the new policy guidelines poses logistical and epistemological challenges. Differences in worldview, inadequate reimbursement, and simple lack of awareness of CIH among medical providers are some of the factors that pose barriers to merging CIH therapies into conventional frameworks. CONCLUSIONS In this article, we explore the potential for a Whole Systems perspective to better explain the complexity of integrating CIH and other non-pharmacological services into a state financed health care system. Oregon's expansion of services for back and neck pain presents an opportunity to explore challenges and successes in melding multiple approaches to health and pain management into a managed system such as the OHP.
Collapse
Affiliation(s)
- Emery R Eaves
- 1 Department of Anthropology, Northern Arizona University, Flagstaff, AZ
| | - Clarissa W Hsu
- 2 Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Lynn L DeBar
- 2 Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | | | - Sarah J McDonald
- 2 Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | - Cheryl Ritenbaugh
- 5 Department of Family and Community Medicine, University of Arizona, Tucson, AZ
| |
Collapse
|
35
|
Shebib R, Bailey JF, Smittenaar P, Perez DA, Mecklenburg G, Hunter S. Randomized controlled trial of a 12-week digital care program in improving low back pain. NPJ Digit Med 2019; 2:1. [PMID: 31304351 PMCID: PMC6550254 DOI: 10.1038/s41746-018-0076-7] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 11/21/2018] [Indexed: 12/29/2022] Open
Abstract
Low back pain (LBP) is the leading cause of disability throughout the world and is economically burdensome. The recommended first line treatment for non-specific LBP is non-invasive care. A digital care program (DCP) delivering evidence-based non-invasive treatment for LBP can aid self-management by engaging patients and scales personalized therapy for patient-specific needs. We assessed the efficacy of a 12-week DCP for LBP in a two-armed, pre-registered, randomized, controlled trial (RCT). Participants were included based on self-reported duration of LBP, but those with surgery or injury to the lower back in the previous three months were excluded. The treatment group (DCP) received the 12-week DCP, consisting of sensor-guided exercise therapy, education, cognitive behavioral therapy, team and individual behavioral coaching, activity tracking, and symptom tracking - all administered remotely via an app. The control group received three digital education articles only. All participants maintained access to treatment-as-usual. At 12 weeks, an intention-to-treat analysis showed each primary outcome-Oswestry Disability Index (p < 0.001), Korff Pain (p < 0.001) and Korff Disability (p < 0.001)-as well as each secondary outcome improved more for participants in the DCP group compared to control group. For participants who completed the DCP (per protocol), average improvement in pain outcomes ranged 52-64% (Korff: 48.8-23.4, VAS: 43.6-16.5, VAS impact on daily life: 37.3-13.4; p < 0.01 for all) and average improvement in disability outcomes ranged 31-55% (Korff: 33.1-15, ODI: 19.7-13.5; p < 0.01 for both). Surgical interest significantly reduced in the DCP group. Participants that completed the DCP had an average engagement, each week, of 90%. Future studies will further explore the effectiveness of the DCP for long-term outcomes beyond 12 weeks and for a LBP patient population with possibly greater baseline pain and disability. In conclusion, the DCP resulted in improved LBP outcomes compared to treatment-as-usual and has potential to scale personalized evidence-based non-invasive treatment for LBP patients.
Collapse
Affiliation(s)
- Raad Shebib
- 1Hinge Health, Inc, San Francisco, CA USA.,2Department of Rehabilitation Services, Kaiser Permanente, San Francisco, CA USA
| | - Jeannie F Bailey
- 3Department of Orthopaedic Surgery, University of California, San Francisco, CA USA
| | | | | | | | | |
Collapse
|
36
|
Zadro JR, Shirley D, Simic M, Mousavi SJ, Ceprnja D, Maka K, Sung J, Ferreira P. Video-Game-Based Exercises for Older People With Chronic Low Back Pain: A Randomized Controlledtable Trial (GAMEBACK). Phys Ther 2019; 99:14-27. [PMID: 30247715 DOI: 10.1093/ptj/pzy112] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 07/16/2018] [Indexed: 11/13/2022]
Abstract
BACKGROUND Video game technology increases adherence to home exercise and could support self-management for older people with chronic low back pain (LBP). OBJECTIVE The objective was to investigate the effects of home-based video game exercises on pain self-efficacy and care-seeking in older people with chronic LBP. DESIGN The study was a randomized controlled trial. SETTING The setting was a community and waiting list. PARTICIPANTS Sixty participants, aged > 55 years with chronic LBP, were randomized (1:1) to Wii Fit U exercises or to continue their usual activities for 8 weeks. INTERVENTION The intervention was home-based Wii Fit U flexibility, strengthening, and aerobic exercises for 60 minutes, 3 times per week, with fortnightly calls from a physical therapist. MEASUREMENTS Measurements included pain self-efficacy and care-seeking (primary outcomes), and physical activity, pain, function, disability, fear of movement/reinjury, falls efficacy, recruitment and response rates, adherence, experience with the intervention, and adverse events (secondary outcomes). RESULTS The mean age of participants was 67.8 (standard deviation = 6.0) years. Adherence to the total recommended exercise time was 70.8%, and no adverse events were reported. Participants completing Wii Fit U exercises had significantly higher pain self-efficacy at 6 months, but not immediately postintervention or at 3 months; there were no between-group differences in care-seeking. Compared with the control group, participants completing Wii Fit U exercises demonstrated significantly greater improvements in pain and function at 8 weeks and were more likely to engage in flexibility exercises at 6 months. There were no significant between-group differences for the remaining outcomes. LIMITATIONS Participants and therapists were not blinded. CONCLUSIONS Wii Fit U exercises improved pain self-efficacy at 6 months, and pain and function immediately postintervention in older people with chronic LBP, but the clinical importance of these changes is questionable. Wii Fit U exercises had no effect on care-seeking, physical activity, disability, fear of movement/reinjury, or falls efficacy.
Collapse
Affiliation(s)
- Joshua R Zadro
- Department of Physiotherapy, Faculty of Health Sciences, The University of Sydney, 75 East St, Lidcombe, NSW 2141, Australia
| | - Debra Shirley
- Department of Physiotherapy, Faculty of Health Sciences, The University of Sydney
| | - Milena Simic
- Department of Physiotherapy, Faculty of Health Sciences, The University of Sydney
| | - Seyed J Mousavi
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, and Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dragana Ceprnja
- Department of Physiotherapy, Westmead Public Hospital, Western Sydney Local Health District, Westmead, NSW, Australia
| | - Katherine Maka
- Department of Physiotherapy, Westmead Public Hospital, Western Sydney Local Health District
| | - Jennie Sung
- Department of Physiotherapy, Westmead Public Hospital, Western Sydney Local Health District
| | - Paulo Ferreira
- Department of Physiotherapy, Faculty of Health Sciences, The University of Sydney
| |
Collapse
|
37
|
van Erp RMA, Huijnen IPJ, Jakobs MLG, Kleijnen J, Smeets RJEM. Effectiveness of Primary Care Interventions Using a Biopsychosocial Approach in Chronic Low Back Pain: A Systematic Review. Pain Pract 2018; 19:224-241. [PMID: 30290052 PMCID: PMC7379915 DOI: 10.1111/papr.12735] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 09/17/2018] [Accepted: 09/27/2018] [Indexed: 02/06/2023]
Abstract
Background and Objective Recent systematic reviews show promising effects for multidisciplinary biopsychosocial (BPS) interventions in patients with chronic low back pain (CLBP). Nowadays, BPS interventions have also been developed for primary care physiotherapy settings. Our aim was to systematically review the evidence on the effectiveness of primary care BPS interventions in improving functional disability, pain, and work status for patients with CLBP. Secondly, we aimed to provide an elaborated overview of BPS intervention designs, physiotherapist training programs, and process‐related factors (practical implementation). Methods We searched in scientific databases and reference lists. Randomized controlled trials (RCTs) evaluating primary care physiotherapist‐led BPS interventions in adults (≥18 years) with nonspecific CLBP (≥12 weeks) were included. Results Our search resulted in 943 references; 7 RCTs were included (1,426 participants). Results show moderate‐quality evidence (3 trials; 991 participants) that a BPS intervention is more effective than education/advice for reducing disability and pain in the short, medium, and long term. Low‐quality evidence (4 trials; 435 participants) was found for no difference with physical activity treatments. Conclusions BPS interventions seem more effective than education/advice and were found to be as effective as physical activity interventions in patients with CLBP. BPS interventions with a clear focus on psychosocial factors (understanding pain, unhelpful thoughts, coping styles, and goal setting) seem most promising. Sufficient delivery of BPS elements is expected when physiotherapists participate in training programs with extensive support prior and during delivery (manual, supervision, and informative resources).
Collapse
Affiliation(s)
- Reni M A van Erp
- Department of Rehabilitation Medicine, CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Ivan P J Huijnen
- Department of Rehabilitation Medicine, CAPHRI, Maastricht University, Maastricht, The Netherlands.,Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Marluuke L G Jakobs
- Faculty of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Jos Kleijnen
- Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Rob J E M Smeets
- Department of Rehabilitation Medicine, CAPHRI, Maastricht University, Maastricht, The Netherlands.,CIR Rehabilitation Location Eindhoven, Eindhoven, the Netherlands
| |
Collapse
|
38
|
Draper-Rodi J, Vogel S, Bishop A. Identification of prognostic factors and assessment methods on the evaluation of non-specific low back pain in a biopsychosocial environment: A scoping review. INT J OSTEOPATH MED 2018. [DOI: 10.1016/j.ijosm.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
39
|
Kjaer P, Kongsted A, Ris I, Abbott A, Rasmussen CDN, Roos EM, Skou ST, Andersen TE, Hartvigsen J. GLA:D ® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence. BMC Musculoskelet Disord 2018; 19:418. [PMID: 30497440 PMCID: PMC6267880 DOI: 10.1186/s12891-018-2334-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/31/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain. METHODS GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created. RESULTS Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions. CONCLUSION From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.
Collapse
Affiliation(s)
- Per Kjaer
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
- Department of Applied Health Services, University College Lillebaelt, Niels Bohrs Alle 1, 5230 Odense M, Denmark
| | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
- Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - Inge Ris
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
| | - Allan Abbott
- Department of Medical and Health Sciences, Division of Physiotherapy, Faculty of Health Sciences, Sandbäcksgatan 7/3, University Hospital Campus, Linköping University, 581 83 Linköping, Sweden
| | | | - Ewa M. Roos
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
| | - Søren T. Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
- Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, 4200 Slagelse, Denmark
| | - Tonny Elmose Andersen
- Department of Psychology, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
- Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| |
Collapse
|
40
|
Williamson E, Ward L, Vadher K, Dutton SJ, Parker B, Petrou S, Hutchinson CE, Gagen R, Arden NK, Barker K, Boniface G, Bruce J, Collins G, Fairbank J, Fitch J, French DP, Garrett A, Gandhi V, Griffiths F, Hansen Z, Mallen C, Morris A, Lamb SE. Better Outcomes for Older people with Spinal Trouble (BOOST) Trial: a randomised controlled trial of a combined physical and psychological intervention for older adults with neurogenic claudication, a protocol. BMJ Open 2018; 8:e022205. [PMID: 30341124 PMCID: PMC6196848 DOI: 10.1136/bmjopen-2018-022205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/21/2018] [Accepted: 08/30/2018] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Neurogenic claudication due to spinal stenosis is common in older adults. The effectiveness of conservative interventions is not known. The aim of the study is to estimate the clinical and cost-effectiveness of a physiotherapist-delivered, combined physical and psychological intervention. METHODS AND ANALYSIS This is a pragmatic, multicentred, randomised controlled trial. Participants are randomised to a combined physical and psychological intervention (Better Outcomes for Older people with Spinal Trouble (BOOST) programme) or best practice advice (control). Community-dwelling adults, 65 years and over, with neurogenic claudication are identified from community and secondary care services. Recruitment is supplemented using a primary care-based cohort. Participants are registered prospectively and randomised in a 2:1 ratio (intervention:control) using a web-based service to ensure allocation concealment. The target sample size is a minimum of 402. The BOOST programme consists of an individual assessment and twelve 90 min classes, including education and discussion underpinned by cognitive behavioural techniques, exercises and walking circuit. During and after the classes, participants undertake home exercises and there are two support telephone calls to promote adherence with the exercises. Best practice advice is delivered in one to three individual sessions with a physiotherapist. The primary outcome is the Oswestry Disability Index at 12 months. Secondary outcomes include the 6 Minute Walk Test, Short Physical Performance Battery, Fear Avoidance Beliefs Questionnaire and Gait Self-Efficacy Scale. Outcomes are measured at 6 and 12 months by researchers who are masked to treatment allocation. The primary statistical analysis will be by 'intention to treat'. There is a parallel health economic evaluation and qualitative study. ETHICS AND DISSEMINATION Ethical approval was given on 3 March 2016 (National Research Ethics Committee number: 16/LO/0349). This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials checklist. The results will be reported at conferences and in peer-reviewed publications using the Consolidated Standards of Reporting Trials guidelines. A plain English summary will be published on the BOOST website. TRIAL REGISTRATION NUMBER ISRCTN12698674; Pre-results.
Collapse
Affiliation(s)
- Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Lesley Ward
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Karan Vadher
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ben Parker
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Richard Gagen
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karen Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Graham Boniface
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Julie Bruce
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gary Collins
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jeremy Fairbank
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Judith Fitch
- Patient and Public Involvement Representative, Yorkshire, UK
| | - David P French
- Manchester Centre for Health Psychology, School of Health Sciences, University of Manchester, Manchester, UK
| | - Angela Garrett
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Varsha Gandhi
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Zara Hansen
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Alana Morris
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
41
|
Snidvongs S, Taylor RS, Ahmad A, Thomson S, Sharma M, Farr A, Fitzsimmons D, Poulton S, Mehta V, Langford R. Facet-joint injections for non-specific low back pain: a feasibility RCT. Health Technol Assess 2018; 21:1-130. [PMID: 29231159 DOI: 10.3310/hta21740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pain of lumbar facet-joint origin is a common cause of low back pain in adults and may lead to chronic pain and disability, with associated health and socioeconomic implications. The socioeconomic burden includes an inability to return to work resulting in loss of productivity in addition to direct and indirect health-care utilisation costs. Lumbar facet-joints are paired synovial joints between the superior and inferior articular processes of consecutive lumbar vertebrae and between the fifth lumbar vertebra and the sacrum. Facet-joint pain is defined as pain that arises from any structure that is part of the facet-joints, including the fibrous capsule, synovial membrane, hyaline cartilage and bone. This pain may be treated by intra-articular injections with local anaesthetic and steroid, although this treatment is not standardised. At present, there is no definitive research to support the use of targeted lumbar facet-joint injections to manage this pain. Because of the lack of high-quality, robust clinical evidence, the National Institute for Health and Care Excellence (NICE) guidelines on the management of chronic low back pain [NICE. Low Back Pain in Adults: Early Management. Clinical guideline (CG88). London: NICE; 2009] did not recommend the use of spinal injections despite their perceived potential to reduce pain intensity and improve rehabilitation, with NICE calling for further research to be undertaken. The updated guidelines [NICE. Low Back Pain and Sciatica in Over 16s: Assessment and Management. NICE guideline (NG59). London: NICE; 2016] again do not recommend the use of spinal injections. OBJECTIVES To assess the feasibility of carrying out a definitive study to evaluate the clinical effectiveness and cost-effectiveness of lumbar facet-joint injections compared with a sham procedure in patients with non-specific low back pain of > 3 months' duration. DESIGN Blinded parallel two-arm pilot randomised controlled trial. SETTING Initially planned as a multicentre study involving three NHS trusts in the UK, recruitment took place in the pain and spinal orthopaedic clinics at Barts Health NHS Trust only. PARTICIPANTS Adult patients referred by their GP to the specialist clinics with non-specific low back pain of at least 3 months' duration despite NICE-recommended best non-invasive care (education and one of a physical exercise programme, acupuncture or manual therapy). Patients who had already received lumbar facet-joint injections or who had had previous back surgery were excluded. INTERVENTIONS Participants who had a positive result following a diagnostic test (single medial branch nerve blocks) were randomised and blinded to receive either intra-articular lumbar facet-joint injections with steroids (intervention group) or a sham procedure (control group). All participants were invited to attend a group-based combined physical and psychological (CPP) programme. MAIN OUTCOME MEASURES In addition to the primary outcome of feasibility, questionnaires were used to assess a range of pain-related (including the Brief Pain Inventory and Short-Form McGill Pain Questionnaire version 2) and disability-related (including the EuroQol-5 Dimensions five-level version and Oswestry Low Back Pain Questionnaire) issues. Health-care utilisation and cost data were also assessed. The questionnaire visits took place at baseline and at 6 weeks, 3 months and 6 months post randomisation. The outcome assessors were blinded to the allocation groups. RESULTS Of 628 participants screened for eligibility, nine were randomised to receive the study intervention (intervention group, n = 5; sham group, n = 4), six completed the CPP programme and eight completed the study. LIMITATIONS Failure to achieve our expected recruitment targets led to early closure of the study by the funder. CONCLUSIONS Because of the small number of participants recruited to the study, we were unable to draw any conclusions about the clinical effectiveness or cost-effectiveness of intra-articular lumbar facet-joint injections in the management of non-specific low back pain. Although we did not achieve the target recruitment rate from the pain clinics, we demonstrated our ability to develop a robust study protocol and deliver the intended interventions safely to all nine randomised participants, thus addressing many of the feasibility objectives. FUTURE WORK Stronger collaborations with primary care may improve the recruitment of patients earlier in their pain trajectory who are suitable for inclusion in a future trial. TRIAL REGISTRATION EudraCT 2014-003187-20 and Current Controlled Trials ISRCTN12191542. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 74. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Saowarat Snidvongs
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Alia Ahmad
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Simon Thomson
- Department of Pain Management, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK
| | - Manohar Sharma
- Department of Pain Medicine, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Angela Farr
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Stephanie Poulton
- Locomotor Pain Service, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Vivek Mehta
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| | - Richard Langford
- Pain and Anaesthesia Research Centre, Barts Health NHS Trust, London, UK
| |
Collapse
|
42
|
Wilson S, Cramp F. Combining a psychological intervention with physiotherapy: A systematic review to determine the effect on physical function and quality of life for adults with chronic pain. PHYSICAL THERAPY REVIEWS 2018. [DOI: 10.1080/10833196.2018.1483550] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Sarah Wilson
- Bath Centre for Pain Services, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Fiona Cramp
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| |
Collapse
|
43
|
Rantonen J, Karppinen J, Vehtari A, Luoto S, Viikari-Juntura E, Hupli M, Malmivaara A, Taimela S. Effectiveness of three interventions for secondary prevention of low back pain in the occupational health setting - a randomised controlled trial with a natural course control. BMC Public Health 2018; 18:598. [PMID: 29739371 PMCID: PMC5941604 DOI: 10.1186/s12889-018-5476-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 04/17/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We assessed the effectiveness of three interventions that were aimed to reduce non-acute low back pain (LBP) related symptoms in the occupational health setting. METHODS Based on a survey (n = 2480; response rate 71%) on LBP, we selected a cohort of 193 employees who reported moderate LBP (Visual Analogue Scale VAS > 34 mm) and fulfilled at least one of the following criteria during the past 12 months: sciatica, recurrence of LBP ≥ 2 times, LBP ≥ 2 weeks, or previous sickness absence. A random sample was extracted from the cohort as a control group (Control, n = 50), representing the natural course of LBP. The remaining 143 employees were invited to participate in a randomised controlled trial (RCT) of three 1:1:1 allocated parallel intervention arms: multidisciplinary rehabilitation (Rehab, n = 43); progressive exercises (Physio, n = 43) and self-care advice (Advice, n = 40). Seventeen employees declined participation in the intervention. The primary outcome measures were physical impairment (PHI), LBP intensity (Visual Analogue Scale), health related quality of life (QoL), and accumulated sickness absence days. We imputed missing values with multiple imputation procedure. We assessed all comparisons between the intervention groups and the Control group by analysing questionnaire outcomes at 2 years with ANOVA and sickness absence at 4 years by using negative binomial model with a logarithmic link function. RESULTS Mean differences between the Rehab and Control groups were - 3 [95% CI -5 to - 1] for PHI, - 13 [- 24 to - 1] for pain intensity, and 0.06 [0.00 to 0.12] for QoL. Mean differences between the Physio and Control groups were - 3 [95% CI -5 to - 1] for PHI, - 13 [- 29 to 2] for pain intensity, and 0.07 [0.01 to 0.13] for QoL. The main effects sizes were from 0.4 to 0.6. The interventions were not effective in reducing sickness absence. CONCLUSIONS Rehab and Physio interventions improved health related quality of life, decreased low back pain and physical impairment in non-acute, moderate LBP, but we found no differences between the Advice and Control group results. No effectiveness on sickness absence was observed. TRIAL REGISTRATION Number NCT00908102 Clinicaltrials.gov.
Collapse
Affiliation(s)
- J. Rantonen
- University of Helsinki, Doctoral School in Health Sciences, Helsinki, Finland
- Lappeenranta University of Technology, Lappeenranta, Finland
- Department of Occupational Medicine, South Karelia Social and Health Care District, Lappeenranta, Finland
| | - J. Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Finnish Institute of Occupational Health, Oulu, Finland
| | - A. Vehtari
- Helsinki Institute for Information Technology HIIT, Department of Computer Science, Aalto University, Espoo, Finland
| | - S. Luoto
- Department of Physical Medicine and Rehabilitation, South Karelia Social and Health Care District, Lappeenranta, Finland
| | | | - M. Hupli
- Department of Physical Medicine and Rehabilitation, South Karelia Social and Health Care District, Lappeenranta, Finland
| | - A. Malmivaara
- National Institute for Health and Welfare, Centre for Health and Social Economics, Helsinki, Finland
| | - S. Taimela
- Evalua International, Espoo, Finland
- Department of Orthopedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
44
|
Keefe FJ, Main CJ, George SZ. Advancing Psychologically Informed Practice for Patients With Persistent Musculoskeletal Pain: Promise, Pitfalls, and Solutions. Phys Ther 2018; 98:398-407. [PMID: 29669084 PMCID: PMC7207297 DOI: 10.1093/ptj/pzy024] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 02/08/2018] [Indexed: 12/28/2022]
Abstract
There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples' responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined.
Collapse
Affiliation(s)
- Francis J Keefe
- Pain Prevention and Treatment Research Program, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27708-0187 (USA)
| | - Chris J Main
- Research Institute for Primary Care & Health Sciences, Keele University, North Staffordshire, United Kingdom
| | - Steven Z George
- Duke Clinical Research Institute, Durham, North Carolina, and Department of Orthopaedic Surgery, Duke University, Durham, North Carolina. Dr George is a Catherine Worthingham Fellow of the American Physical Therapy Association
| |
Collapse
|
45
|
Bérubé M, Gélinas C, Feeley N, Martorella G, Côté J, Laflamme GY, Rouleau DM, Choinière M. A Hybrid Web-Based and In-Person Self-Management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma: Feasibility and Acceptability of iPACT-E-Trauma. JMIR Form Res 2018; 2:e10323. [PMID: 30684418 PMCID: PMC6334695 DOI: 10.2196/10323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/11/2018] [Accepted: 04/14/2018] [Indexed: 12/31/2022] Open
Abstract
Background A transition from acute to chronic pain frequently occurs after major lower extremity trauma. While the risk factors for developing chronic pain in this population have been extensively studied, research findings on interventions aiming to prevent chronic pain in the trauma context are scarce. Therefore, we developed a hybrid, Web-based and in-person, self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma). Objective This study aimed to assess the feasibility and acceptability of iPACT-E-Trauma. Methods Using a descriptive design, the intervention was initiated at a supra-regional level-1 trauma center. Twenty-eight patients ≥18 years old with major lower extremity trauma, presenting with moderate to high pain intensity 24 hours post-injury were recruited. Feasibility assessment was two-fold: 1) whether the intervention components could be provided as planned to ≥80% of participants and 2) whether ≥80% of participants could complete the intervention. The rates for both these variables were calculated. The E-Health Acceptability Questionnaire and the Treatment Acceptability and Preference Questionnaire were used to assess acceptability. Mean scores were computed to determine the intervention’s acceptability. Results More than 80% of participants received the session components relevant to their condition. However, the Web pages for session 2, on the analgesics prescribed, were accessed by 71% of participants. Most sessions were delivered according to the established timeline for ≥80% of participants. Session 3 and in-person coaching meetings had to be provider earlier for ≥35% of participants. Session duration was 30 minutes or less on average, as initially planned. More than 80% of participants attended sessions and <20% did not apply self-management behaviors relevant to their condition, with the exception of deep breathing relaxation exercises which was not applied by 40% of them. Web and in-person sessions were assessed as very acceptable (mean scores ≥3 on a 0 to 4 descriptive scale) across nearly all acceptability attributes. Conclusions Findings showed that the iPACT-E-Trauma intervention is feasible and was perceived as highly acceptable by participants. Further tailoring iPACT-E-Trauma to patient needs, providing more training time for relaxation techniques, and modifying the Web platform to improve its convenience could enhance the feasibility and acceptability of the intervention. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6ynibjPHa)
Collapse
Affiliation(s)
- Mélanie Bérubé
- Centre intégré universitaire du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Trauma Program and Department of Nursing, Montreal, QC, Canada.,Ingram School of Nursing, McGill University, Montreal, QC, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, QC, Canada.,Centre for Nursing Research, Jewish General Hospital, Montreal, QC, Canada
| | - Nancy Feeley
- Ingram School of Nursing, McGill University, Montreal, QC, Canada.,Centre for Nursing Research, Jewish General Hospital, Montreal, QC, Canada
| | | | - José Côté
- Faculté des sciences infirmières, Université de Montréal, Montreal, QC, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - G Yves Laflamme
- Centre intégré universitaire du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Dominique M Rouleau
- Centre intégré universitaire du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Manon Choinière
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Department of Anesthesiology, Université de Montréal, Montreal, QC, Canada
| |
Collapse
|
46
|
Ellard DR, Underwood M, Achana F, Antrobus JH, Balasubramanian S, Brown S, Cairns M, Griffin J, Griffiths F, Haywood K, Hutchinson C, Lall R, Petrou S, Stallard N, Tysall C, Walsh DA, Sandhu H. Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial. Health Technol Assess 2018. [PMID: 28639551 DOI: 10.3310/hta21300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. OBJECTIVES To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. DESIGN The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. SETTING Five NHS acute trusts in England. PARTICIPANTS Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone. INTERVENTIONS All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. MAIN OUTCOME MEASURES Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. RESULTS Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. LIMITATIONS Poor recruitment was a limiting factor. CONCLUSIONS This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain. FUTURE WORK Further work is needed to test recruitment from alternative clinical situations. TRIAL REGISTRATION EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Felix Achana
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - James Hl Antrobus
- South Warwickshire NHS Foundation Trust, Warwick Hospital, Warwick, UK
| | - Shyam Balasubramanian
- Pain Management Service, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Sally Brown
- University/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - Melinda Cairns
- Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - James Griffin
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Frances Griffiths
- Social Science and Systems in Health, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Kirstie Haywood
- Royal College of Nursing Research Institute, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Hutchinson
- Population Evidence and Technologies Room, Warwick Medical School, University of Warwick, University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Colin Tysall
- University/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - David A Walsh
- Arthritis Research UK Pain Centre, Academic Rheumatology, University of Nottingham, Nottingham, UK
| | - Harbinder Sandhu
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
47
|
Klinge M, Coppler T, Liebschutz JM, Dugum M, Wassan A, DiMartini A, Rogal S. The assessment and management of pain in cirrhosis. ACTA ACUST UNITED AC 2018; 17:42-51. [PMID: 29552453 DOI: 10.1007/s11901-018-0389-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review The treatment of pain in patients with cirrhosis is complicated by unpredictable hepatic drug metabolism and a higher risk of adverse drug reactions. We aimed to conduct a scoping review regarding pain management in cirrhosis. Recent findings Despite the high prevalence of pain in patients with cirrhosis, there is little literature to guide the management of pain in this population. Complex pain syndromes and disease-specific pain etiologies exist are common in patients with cirrhosis. There are numerous contraindications and limitations when considering pharmacotherapy for analgesia in cirrhosis, specifically with non-steroidal anti-inflammatory drugs (NSAIDS) and opioid medications. Non-pharmacologic therapies for pain have not been specifically assessed in this population. Summary As with other populations, a multi-dimensional treatment approach to pain with a focus on physical, behavioral, procedural and pharmacologic treatment is recommended when caring for patients with cirrhosis and pain. However, more research is needed to evaluate opioid-sparing and non-pharmacologic analgesia in this population.
Collapse
Affiliation(s)
- Matthew Klinge
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh
| | - Tami Coppler
- Division of Pharmacy, VA Pittsburgh Healthcare System
| | | | - Mohannad Dugum
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh
| | - Ajay Wassan
- Department of Anesthesiology, University of Pittsburgh
| | - Andrea DiMartini
- Department of Psychiatry, University of Pittsburgh.,Department of Surgery, University of Pittsburgh
| | - Shari Rogal
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh.,Department of Surgery, University of Pittsburgh.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| |
Collapse
|
48
|
Green D, Lewis M, Mansell G, Artus M, Dziedzic K, Hay E, Foster N, van der Windt D. Clinical course and prognostic factors across different musculoskeletal pain sites: A secondary analysis of individual patient data from randomised clinical trials. Eur J Pain 2018; 22:1057-1070. [DOI: 10.1002/ejp.1190] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2018] [Indexed: 12/19/2022]
Affiliation(s)
- D.J. Green
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - M. Lewis
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - G. Mansell
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - M. Artus
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - K.S. Dziedzic
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - E.M. Hay
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - N.E. Foster
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| | - D.A. van der Windt
- Arthritis Research UK Primary Care Centre (Research Institute for Primary Care & Health Sciences) & Keele Clinical Trials Unit (David Weatherall Building); Keele University; Keele ST5 5BG UK
| |
Collapse
|
49
|
Raftery J, Hanney S, Greenhalgh T, Glover M, Blatch-Jones A. Models and applications for measuring the impact of health research: update of a systematic review for the Health Technology Assessment programme. Health Technol Assess 2018; 20:1-254. [PMID: 27767013 DOI: 10.3310/hta20760] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This report reviews approaches and tools for measuring the impact of research programmes, building on, and extending, a 2007 review. OBJECTIVES (1) To identify the range of theoretical models and empirical approaches for measuring the impact of health research programmes; (2) to develop a taxonomy of models and approaches; (3) to summarise the evidence on the application and use of these models; and (4) to evaluate the different options for the Health Technology Assessment (HTA) programme. DATA SOURCES We searched databases including Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and The Cochrane Library from January 2005 to August 2014. REVIEW METHODS This narrative systematic literature review comprised an update, extension and analysis/discussion. We systematically searched eight databases, supplemented by personal knowledge, in August 2014 through to March 2015. RESULTS The literature on impact assessment has much expanded. The Payback Framework, with adaptations, remains the most widely used approach. It draws on different philosophical traditions, enhancing an underlying logic model with an interpretative case study element and attention to context. Besides the logic model, other ideal type approaches included constructionist, realist, critical and performative. Most models in practice drew pragmatically on elements of several ideal types. Monetisation of impact, an increasingly popular approach, shows a high return from research but relies heavily on assumptions about the extent to which health gains depend on research. Despite usually requiring systematic reviews before funding trials, the HTA programme does not routinely examine the impact of those trials on subsequent systematic reviews. The York/Patient-Centered Outcomes Research Institute and the Grading of Recommendations Assessment, Development and Evaluation toolkits provide ways of assessing such impact, but need to be evaluated. The literature, as reviewed here, provides very few instances of a randomised trial playing a major role in stopping the use of a new technology. The few trials funded by the HTA programme that may have played such a role were outliers. DISCUSSION The findings of this review support the continued use of the Payback Framework by the HTA programme. Changes in the structure of the NHS, the development of NHS England and changes in the National Institute for Health and Care Excellence's remit pose new challenges for identifying and meeting current and future research needs. Future assessments of the impact of the HTA programme will have to take account of wider changes, especially as the Research Excellence Framework (REF), which assesses the quality of universities' research, seems likely to continue to rely on case studies to measure impact. The HTA programme should consider how the format and selection of case studies might be improved to aid more systematic assessment. The selection of case studies, such as in the REF, but also more generally, tends to be biased towards high-impact rather than low-impact stories. Experience for other industries indicate that much can be learnt from the latter. The adoption of researchfish® (researchfish Ltd, Cambridge, UK) by most major UK research funders has implications for future assessments of impact. Although the routine capture of indexed research publications has merit, the degree to which researchfish will succeed in collecting other, non-indexed outputs and activities remains to be established. LIMITATIONS There were limitations in how far we could address challenges that faced us as we extended the focus beyond that of the 2007 review, and well beyond a narrow focus just on the HTA programme. CONCLUSIONS Research funders can benefit from continuing to monitor and evaluate the impacts of the studies they fund. They should also review the contribution of case studies and expand work on linking trials to meta-analyses and to guidelines. FUNDING The National Institute for Health Research HTA programme.
Collapse
Affiliation(s)
- James Raftery
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Steve Hanney
- Health Economics Research Group (HERG), Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Matthew Glover
- Health Economics Research Group (HERG), Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Amanda Blatch-Jones
- Wessex Institute, Faculty of Medicine, University of Southampton, Southampton, UK
| |
Collapse
|
50
|
Darlow B, Stanley J, Dean S, Abbott JH, Garrett S, Mathieson F, Dowell A. The Fear Reduction Exercised Early (FREE) approach to low back pain: study protocol for a randomised controlled trial. Trials 2017; 18:484. [PMID: 29041947 PMCID: PMC5646107 DOI: 10.1186/s13063-017-2225-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/29/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Low back pain (LBP) is a major health issue associated with considerable health loss and societal costs. General practitioners (GPs) play an important role in the management of LBP; however, GP care has not been shown to be the most cost-effective approach unless exercise and behavioural counselling are added to usual care. The Fear Reduction Exercised Early (FREE) approach to LBP has been developed to assist GPs to manage LBP by empowering exploration and management of psychosocial barriers to recovery and provision of evidence-based care and information. The aim of the Low Back Pain in General Practice (LBPinGP) trial is to explore whether patients with LBP who receive care from GPs trained in the FREE approach have better outcomes than those who receive usual care. METHODS/DESIGN This is a cluster randomised controlled superiority trial comparing the FREE approach with usual care for LBP management with investigator-blinded assessment of outcomes. GPs will be recruited and then cluster randomised (in practice groups) to the intervention or control arm. Intervention arm GPs will receive training in the FREE approach, and control arm GPs will continue to practice as usual. Patients presenting to their GP with a primary complaint of LBP will be allocated on the basis of allocation of the GP they consult. We aim to recruit 60 GPs and 275 patients (assuming patients are recruited from 75% of GPs and an average of 5 patients per GP complete the study, accounting for 20% patient participant dropout). Patient participants and the trial statistician will be blind to group allocation throughout the study. Analyses will be undertaken on an intention-to-treat basis. The primary outcome will be back-related functional impairment 6 months post-initial LBP consultation (interim data at 2 weeks, 6 weeks and 3 months), measured with the Roland-Morris Disability Questionnaire. Secondary patient outcomes include pain, satisfaction, quality of life, days off from work and costs of care. Secondary GP outcomes include beliefs about pain and impairment, GP confidence, and actual and reported clinical behaviour. Health economic and process evaluations will be conducted. DISCUSSION In the LBPinGP trial, we will investigate providing an intervention during the first interaction a person with back pain has with their GP. Because the FREE approach is used within a normal GP consultation, if effective, it may be a cost-effective means of improving LBP care. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12616000888460 . Registered on 6 July 2016.
Collapse
Affiliation(s)
- Ben Darlow
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand.
| | - James Stanley
- Biostatistical Group, Dean's Department, University of Otago, Wellington, New Zealand
| | - Sarah Dean
- Medical School, University of Exeter, Exeter, UK
| | - J Haxby Abbott
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Sue Garrett
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
| | - Fiona Mathieson
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Anthony Dowell
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
| |
Collapse
|