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Stevenson RDM, Chowdhury EA, Inza VB, Western MJ, Walsh NE, Jones SL, Bilzon JLJ. Development of the intelligent knee osteoarthritis lifestyle app: a person-based approach. BMC Musculoskelet Disord 2024; 25:189. [PMID: 38431553 PMCID: PMC10908108 DOI: 10.1186/s12891-024-07313-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/26/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Knee osteoarthritis is one of the most prevalent long term health conditions globally. Exercise and physical activity are now widely recognised to significantly reduce joint pain, improve physical function and quality of life in patients with knee osteoarthritis. However, prescribed exercise without regular contact with a healthcare professional often results in lower adherence and poorer health outcomes. Digital mobile health (mHealth) technologies offer great potential to support people with long-term conditions such as knee osteoarthritis more efficiently and effectively and with relatively lower cost than existing interventions. However, there are currently very few mHealth interventions for the self-management of knee osteoarthritis. The aim of the present study was to describe the development process of a mHealth app to extend the support for physical activity and musculoskeletal health beyond short-term, structured rehabilitation through self-management, personalised physical activity, education, and social support. METHODS The development of the intelligent knee osteoarthritis lifestyle application intervention involved an iterative and interconnected process comprising intervention 'planning' and 'optimisation' informed by the person-based approach framework for the development of digital health interventions. The planning phase involved a literature review and collection of qualitative data obtained from focus groups with individuals with knee osteoarthritis (n = 26) and interviews with relevant physiotherapists (n = 5) to generate 'guiding principles' for the intervention. The optimisation phase involved usability testing (n = 7) and qualitative 'think aloud' sessions (n = 6) with potential beneficiaries to refine the development of the intervention. RESULTS Key themes that emerged from the qualitative data included the need for educational material, modifying activities to suit individual abilities and preferences as well as the inclusion of key features such as rehabilitation exercises. Following a user-trial further changes were made to improve the usability of the application. CONCLUSIONS Using a systematic person-based, development approach, we have developed the intelligent knee osteoarthritis lifestyle application to help people maintain physical activity behaviour. The app extends the support for physical activity and musculoskeletal health beyond short-term, structured rehabilitation through personalised physical activity guidance, education, and social support.
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Affiliation(s)
- Richard D M Stevenson
- Department for Health, The University of Bath, Bath, BA2 7AY, UK
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Bath, Bath, UK
| | - Enhad A Chowdhury
- Department for Health, The University of Bath, Bath, BA2 7AY, UK
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Bath, Bath, UK
| | - Victor B Inza
- Visual Computing Centre, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
| | - Max J Western
- Department for Health, The University of Bath, Bath, BA2 7AY, UK
| | - Nicola E Walsh
- Faculty of Health and Applied Science, University of the West of England, Bristol, UK
| | - Simon L Jones
- Department of Computer Science, The University of Bath, Bath, BA2 7AY, UK
| | - James L J Bilzon
- Department for Health, The University of Bath, Bath, BA2 7AY, UK.
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Bath, Bath, UK.
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Turnbull S, Walsh NE, Moore AJ. Adaptation and Implementation of a Shared Decision-Making Tool From One Health Context to Another: Partnership Approach Using Mixed Methods. J Med Internet Res 2023; 25:e42551. [PMID: 37405845 DOI: 10.2196/42551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/04/2023] [Accepted: 05/27/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Osteoarthritis is a leading cause of pain and disability. Knee osteoarthritis accounts for nearly four-fifths of the burden of osteoarthritis internationally, and 10% of adults in the United Kingdom have the condition. Shared decision-making (SDM) supports patients to make more informed choices about treatment and care while reducing inequities in access to treatment. We evaluated the experience of a team adapting an SDM tool for knee osteoarthritis and the tool's implementation potential within a local clinical commissioning group (CCG) area in southwest England. The tool aims to prepare patients and clinicians for SDM by providing evidence-based information about treatment options relevant to disease stage. OBJECTIVE This study aimed to explore the experiences of a team adapting an SDM tool from one health context to another and the implementation potential of the tool in the local CCG area. METHODS A partnership approach using mixed methods was used to respond to recruitment challenges and ensure that study aims could be addressed within time restrictions. A web-based survey was used to obtain clinicians' feedback on experiences of using the SDM tool. Qualitative interviews were conducted by telephone or video call with a sample of stakeholders involved in adapting and implementing the tool in the local CCG area. Survey findings were summarized as frequencies and percentages. Content analysis was conducted on qualitative data using framework analysis, and data were mapped directly to the Theoretical Domains Framework (TDF). RESULTS Overall, 23 clinicians completed the survey, including first-contact physiotherapists (11/23, 48%), physiotherapists (7/23, 30%), specialist physiotherapists (4/23, 17%), and a general practitioner (1/23, 4%). Eight stakeholders involved in commissioning, adapting, and implementing the SDM tool were interviewed. Participants described barriers and facilitators to the adaptation, implementation, and use of the tool. Barriers included a lack of organizational culture that supported and resourced SDM, lack of clinician buy-in and awareness of the tool, challenges with accessibility and usability, and lack of adaptation for underserved communities. Facilitators included the influence of clinical leaders' belief that SDM tools can improve patient outcomes and National Health Service resource use, clinicians' positive experiences of using the tool, and improving awareness of the tool. Themes were mapped to 13 of the 14 TDF domains. Usability issues were described, which did not map to the TDF domains. CONCLUSIONS This study highlights barriers and facilitators to adapting and implementing tools from one health context to another. We recommend that tools selected for adaptation should have a strong evidence base, including evidence of effectiveness and acceptability in the original context. Legal advice should be sought regarding intellectual property early in the project. Existing guidance for developing and adapting interventions should be used. Co-design methods should be applied to improve adapted tools' accessibility and acceptability.
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Affiliation(s)
- Sophie Turnbull
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Nicola E Walsh
- Centre for Health and Clinical Research, University of the West of England, Bristol, United Kingdom
| | - Andrew J Moore
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
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Moore AJ, Wylde V, Whitehouse MR, Beswick AD, Walsh NE, Jameson C, Blom AW. Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection. Bone Jt Open 2023; 4:226-233. [PMID: 37051823 PMCID: PMC10065846 DOI: 10.1302/2633-1462.44.bjo-2022-0155.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Aims Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. Methods We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. Results The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. Conclusion We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection. Cite this article: Bone Jt Open 2023;4(4):226–233.
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Affiliation(s)
- Andrew J. Moore
- University of Bristol, Bristol, UK
- Correspondence should be sent to Andrew J. Moore. E-mail:
| | | | | | | | - Nicola E. Walsh
- HAS - Allied Health Professions, University of the West of England, Bristol, UK
| | | | - Ashley W. Blom
- University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
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Jagosh J, Stott H, Halls S, Thomas R, Liddiard C, Cupples M, Cramp F, Kersten P, Foster D, Walsh NE. Benefits of realist evaluation for rapidly changing health service delivery. BMJ Open 2022; 12:e060347. [PMID: 35896288 PMCID: PMC9335061 DOI: 10.1136/bmjopen-2021-060347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Realist evaluation is a methodology that addresses the questions: 'what works, for whom, in which circumstances, and how?'. In this approach, programme theories are developed and tested against available evidence. However, when complex interventions are implemented in rapidly changing environments, there are many unpredictable forces that determine the programme's scope and architecture, as well as resultant outcome. These forces can be theorised, in real time, and included in realist evaluation outputs for current and future optimisation of programmes. Reflecting on a realist evaluation of first-contact physiotherapy in primary care (the FRONTIER Study), five important considerations are described for improving the quality of realist evaluation outputs when studying rapidly changing health service delivery. These are: (1) ensuring that initial programme theories are developed through creative thinking sessions, empirical and non-empirical literature, and stakeholder consultation; (2) testing the causal impact of formal and informal (eg, emergent) components of service delivery models; (3) contrasting initial programme theories with rival theory statements; (4) envisioning broad system impacts beyond the immediate implementation setting; and (5) incorporating rapidly evolving service developments and context changes into the theory testing process in real-time (eg, Additional Role Reimbursement Scheme, COVID-19). Through the reflections presented, the aim is to clarify the benefit of realist evaluation to assess emerging models of care and rapidly changing health service delivery.
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Affiliation(s)
- Justin Jagosh
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, UK
| | - Hannah Stott
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, UK
| | - Serena Halls
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, UK
| | - Rachel Thomas
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, UK
| | - Cathy Liddiard
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, UK
| | | | - Fiona Cramp
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, UK
| | - Paula Kersten
- School of Health Sciences, Canterbury Christ Church University, Canterbury, UK
| | - Dave Foster
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, UK
| | - Nicola E Walsh
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, UK
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5
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Pearson J, Coggins J, Derham S, Russell J, Walsh NE, Lenguerrand E, Palmer S, Cramp F. A feasibility randomised controlled trial of a Fibromyalgia Self-management Programme for adults in a community setting with a nested qualitative study (FALCON). BMC Musculoskelet Disord 2022; 23:656. [PMID: 35820832 PMCID: PMC9274955 DOI: 10.1186/s12891-022-05529-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Fibromyalgia is a condition associated with widespread musculoskeletal pain, fatigue and sleep problems. Fibromyalgia treatment guidelines recommend non-pharmacological interventions and the development of self-management skills. An example of a programme that fits these guidelines is the Fibromyalgia Self-management Programme (FSMP) which consists of one 2.5-hour weekly session over six successive weeks and includes education about fibromyalgia, goal setting, pacing, sleep hygiene and nutritional advice. The FSMP is currently provided in a secondary care hospital setting and co-delivered by a multidisciplinary team. Delivery in a primary care setting has the potential to improve the accessibility of the programme to people with fibromyalgia. Therefore, this feasibility study aimed to determine the practicality and acceptability of conducting a future definitive randomised controlled trial of the FSMP in a community setting. Method An exploratory, parallel-arm, one-to-one, randomised controlled trial. Participants were recruited from general practices across South West England, and the FSMP was co-delivered by physiotherapists and occupational therapists across two community sites. To determine the outcome measures for a future definitive trial several were tested. The Revised Fibromyalgia Impact Questionnaire, Arthritis Self-Efficacy Scale-8, Chalder Fatigue Scale, Short form 36, 5-Level EQ-5D version and Jenkins Sleep Scale were collected at baseline, 6 weeks and 6 months. Semi-structured interviews were conducted with patient participants, occupational therapists and physiotherapists to explore the acceptability and feasibility of delivering the FSMP in a community setting. Results A total of 74 participants were randomised to the FSMP intervention (n = 38) or control arm (n = 36). Attrition from the trial was 42% (31/74) at 6 months. A large proportion of those randomised to the intervention arm (34%, 13/38) failed to attend any sessions with six of the 13 withdrawing before the intervention commenced. The proportion of missing values was small for each of the outcome measures. Three overarching themes were derived from the interview data; (1) barriers and facilitators to attending the FSMP; (2) FSMP content, delivery and supporting documentation; and (3) trial processes. Conclusion It is feasible to recruit people with fibromyalgia from Primary Care to participate in a randomised controlled trial testing the FSMP in a community setting. However, improvement in trial attrition and engagement with the intervention is needed. Trial registration The trial is registered with ISRCTN registry and was assigned on 29/04/2019. The registration number is ISRCTN10824225.
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Affiliation(s)
- Jennifer Pearson
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Bristol, UK. .,Brownsword Therapies Centre, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.
| | - Jessica Coggins
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Bristol, UK
| | - Sandi Derham
- Brownsword Therapies Centre, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Julie Russell
- Brownsword Therapies Centre, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Nicola E Walsh
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shea Palmer
- Centre for Care Excellence, Coventry University and University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Fiona Cramp
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Bristol, UK
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Preece SJ, Brookes N, Williams AE, Jones RK, Starbuck C, Jones A, Walsh NE. Correction to: A new integrated behavioural intervention for knee osteoarthritis: development and pilot study. BMC Musculoskelet Disord 2022; 23:83. [PMID: 35078454 PMCID: PMC8790912 DOI: 10.1186/s12891-021-04993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Stephen J Preece
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK.
| | - Nathan Brookes
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK.,Physiotherapy Department, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Anita E Williams
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK
| | - Richard K Jones
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK
| | - Chelsea Starbuck
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK
| | - Anthony Jones
- Human Pain Research Group, University of Manchester, Clinical Sciences Building, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Nicola E Walsh
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, BS16 1DD, UK
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Preece SJ, Brookes N, Williams AE, Jones RK, Starbuck C, Jones A, Walsh NE. A new integrated behavioural intervention for knee osteoarthritis: development and pilot study. BMC Musculoskelet Disord 2021; 22:526. [PMID: 34103040 PMCID: PMC8188786 DOI: 10.1186/s12891-021-04389-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/30/2021] [Indexed: 01/04/2023] Open
Abstract
Background Exercise-based approaches have been a cornerstone of physiotherapy management of knee osteoarthritis for many years. However, clinical effects are considered small to modest and the need for continued adherence identified as a barrier to clinical efficacy. While exercise-based approaches focus on muscle strengthening, biomechanical research has identified that people with knee osteoarthritis over activate their muscles during functional tasks. Therefore, we aimed to create a new behavioural intervention, which integrated psychologically informed practice with biofeedback training to reduce muscle overactivity, and which was suitable for delivery by a physiotherapist. Methods Through literature review, we created a framework linking theory from pain science with emerging biomechanical concepts related to overactivity of the knee muscles. Using recognised behaviour change theory, we then mapped a set of intervention components which were iteratively developed through ongoing testing and consultation with patients and physiotherapists. Results The underlying framework incorporated ideas related to central sensitisation, motor responses to pain and also focused on the idea that increased knee muscle overactivity could result from postural compensation. Building on these ideas, we created an intervention with five components: making sense of pain, general relaxation, postural deconstruction, responding differently to pain and functional muscle retraining. The intervention incorporated a range of animated instructional videos to communicate concepts related to pain and biomechanical theory and also used EMG biofeedback to facilitate visualization of muscle patterns. User feedback was positive with patients describing the intervention as enabling them to “create a new normal” and to be “in control of their own treatment.” Furthermore, large reductions in pain were observed from 11 patients who received a prototype version of the intervention. Conclusion We have created a new intervention for knee osteoarthritis, designed to empower individuals with capability and motivation to change muscle activation patterns and beliefs associated with pain. We refer to this intervention as Cognitive Muscular Therapy. Preliminary feedback and clinical indications are positive, motivating future large-scale trials to understand potential efficacy. It is possible that this new approach could bring about improvements in the pain associated with knee osteoarthritis without the need for continued adherence to muscle strengthening programmes. Trial registration ISRCTN51913166 (Registered 24-02-2020, Retrospectively registered). Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04389-0.
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Affiliation(s)
- Stephen J Preece
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK.
| | - Nathan Brookes
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK.,Physiotherapy Department, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Anita E Williams
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK
| | - Richard K Jones
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK
| | - Chelsea Starbuck
- Centre for Health Sciences Research, University of Salford, Manchester, M6 6PU, UK
| | - Anthony Jones
- Human Pain Research Group, University of Manchester, Clinical Sciences Building, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Nicola E Walsh
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, BS16 1DD, UK
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Chowdhury EA, Inza VC, Western MJ, Walsh NE, Bilzon JLJ, Jones SL. P106 Planning and development of a long-term digital self-management tool for osteoarthritis: the Intelligent Knee Osteoarthritis Lifestyle App. Rheumatology (Oxford) 2021. [DOI: 10.1093/rheumatology/keab247.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Aims
There is strong evidence for beneficial effects of physical activity for people with knee osteoarthritis (KOA). While supervised exercise programmes are effective, they are resource intensive, typically of limited duration and hard to implement at scale. More accessible options should be developed to enable individuals to adopt and maintain appropriate physically active lifestyles. Smartphone apps can monitor activity and symptoms, providing feedback to support self-management. We aimed to co-design a KOA self-management app, with physiotherapists and people experiencing KOA, to support long-term physical activity.
Methods
We followed the Person-Based Approach to developing health interventions. We initially undertook a rapid review of clinical exercise guidelines and KOA position statements. Views from potential app users were elicited via focus groups, to determine attitudes towards physical activity, KOA self-management technology, and identify desired app features. Physiotherapists were interviewed to establish factors that feed into physical activity advice and recommendations in a clinical context, and determine which features they deemed appropriate to incorporate into an app. We then mapped established behaviour change techniques to potential features. Combining these sources of information, we developed guiding principles, then iteratively developed and refined the app through “think aloud” interviews with potential users and interviews with physiotherapists to assess appropriateness and safety.
Results
Literature scoping established positive effects for a range of exercise modes, with NICE guidelines highlighting physical activity, education and weight management as core treatments for KOA. Patient focus groups highlighted uncertainty about the potential benefits and/or harms associated with physical activity, as well as confusion regarding appropriate sources of information. Patients emphasised the importance of symptom tracking and the benefits of social support as an important factor in motivation to engage in and sustain activity. Interviews with physiotherapists revealed physical and psycho-social characteristics of patients to consider when recommending physical activities. Physiotherapists and patients both expressed the necessity for activities to be tailored to individual capabilities and preferences.
Conclusion
The Intelligent Knee Osteoarthritis Lifestyle App (iKOALA) is an evidence-based smartphone app to support long-term self-management for individuals with KOA. The app facilitates appropriate physical activity adoption and maintenance; provides feedback from linked wearable activity trackers; gives information and intelligently tailored physical activity options from patient preferences and symptoms. Broader self-management aspects include rehabilitation exercise content, symptom tracking and alerts, weight management tools and education resources. Crucially, for long-term maintenance, the app includes forum features, fostering social relatedness among users. The app has received positive feedback from potential users in terms of usability and perceived utility. Physiotherapists have provided positive clinical impressions and validated the appropriateness of the content and features. The app is undergoing extended user testing with patients, following which, we aim to assess the effectiveness of the app in a randomised trial.
Disclosure
E.A. Chowdhury: None. V. Ceballos Inza: None. M.J. Western: None. N.E. Walsh: None. J.L.J. Bilzon: None. S.L. Jones: None.
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Affiliation(s)
- Enhad A Chowdhury
- Department for Health, University of Bath, Bath, UNITED KINGDOM
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Bath, Bath, UNITED KINGDOM
| | - Victor Ceballos Inza
- Visual Computing Centre, King Abdullah University of Science and Technology, Thuwal, SAUDI ARABIA
- Department of Computer Science, University of Bath, Bath, UNITED KINGDOM
| | - Max J Western
- Department for Health, University of Bath, Bath, UNITED KINGDOM
- Centre for Motivation and Health Behaviour Change, University of Bath, Bath, UNITED KINGDOM
| | - Nicola E Walsh
- Centre for Health and Clinical Research, University of the West of England, Bristol, UNITED KINGDOM
| | - James L J Bilzon
- Department for Health, University of Bath, Bath, UNITED KINGDOM
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Bath, Bath, UNITED KINGDOM
| | - Simon L Jones
- Department of Computer Science, University of Bath, Bath, UNITED KINGDOM
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Pearson J, Coggins J, Lenguerrand E, Derham S, Russell J, Walsh NE, Cramp F. A feasibility randomised controlled trial of a fibromyalgia self-management programme in a community setting with a nested qualitative study (FALCON): Study protocol. Musculoskeletal Care 2020; 19:59-66. [PMID: 32890429 DOI: 10.1002/msc.1509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fibromyalgia (FM) is a complex long-term condition associated with chronic widespread pain, fatigue, sleep problems, memory and concentration difficulties and irritable bowel syndrome. Current guidelines for the treatment of FM recommend nonpharmacological interventions. The Fibromyalgia Self-Management Programme (FSMP) is a nonpharmacological, multidisciplinary exercise and education group intervention. It aims to provide education and teach core skills, enabling those affected by FM to self-manage. The FSMP is currently codelivered by a multidisciplinary team within a secondary care service. The aim of this feasibility randomised controlled trial (RCT) is to determine the practicality and acceptability of delivering the FSMP in a community setting, informing a future RCT of effectiveness. METHODS The feasibility RCT aims to recruit 70 people with FM. Participants will be randomised to either a community FSMP or control arm. All participants will be asked to complete six patient-reported outcome measures and one health economics questionnaire on three occasions; baseline, 6 weeks (end of the intervention) and 6 months. Between 12 and 16 participants and four therapists delivering the FSMP will be invited to take part in a semi-structured interview to explore their experiences of the FSMP. Patient participants will be purposively selected based upon key characteristics. ANALYSIS Quantitative data will be analysed descriptively to summarise recruitment and attendance, participant reported outcomes and health economic data. Semi-structured interviews will be transcribed, anonymised and inductively coded. The codes will be grouped into categories and theoretically thematically analysed, comparing the results to existing literature. TRIAL REGISTRATION The trial is registered with ISRCTN registry and was assigned on 29th of April 2020. The registration number is ISRCTN10824225.
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Affiliation(s)
- Jennifer Pearson
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, Bristol, UK.,Therapy Department, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Jessica Coggins
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sandi Derham
- Therapy Department, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Julie Russell
- Therapy Department, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Nicola E Walsh
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, Bristol, UK
| | - Fiona Cramp
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, Bristol, UK
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10
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Cramp F, Thomas R, Haase AM, Domaille M, Manns S, Swales C, Hurfurt J, Walsh NE. Promoting engagement in physical activity in early rheumatoid arthritis: A proof-of-concept intervention study. Musculoskeletal Care 2020; 18:487-500. [PMID: 32666652 DOI: 10.1002/msc.1493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE(S) The aim of this study is to test the feasibility and acceptability of promoting engagement in physical activity in early rheumatoid arthritis (PEPA-RA) to inform a future trial. DESIGN A 'proof of concept' study was carried out. SETTING This study was conducted in community hospitals delivered by musculoskeletal primary care physiotherapists. PARTICIPANTS Participants were 12 adults with rheumatoid arthritis (RA) diagnosed 6-24 months previously (nine females, three males; mean age 58 years, range 23-79). INTERVENTION The intervention consisted of five sessions, that is, four group sessions and one individual session facilitated by a physiotherapist over 12 weeks including patient education and support for behaviour change as well as supervised practical exercise. MAIN OUTCOMES The main outcomes were attendance, completion of outcome measures, adverse events, and participant and physiotherapist feedback views relating to the intervention. RESULTS Overall attendance was 85%, with sessions missed due to illness or RA flare. Outcome measure completion ranged from 83% to 100%. There were no clinically meaningful changes in pain or function at 12 weeks, but mean 6-min walk distance improved from 394 to 440 m. No serious adverse events were reported, and participants were generally positive about the intervention. Suggested minor modifications for the group sessions included venue accessibility and ensuring that physical activity time was protected. Several participants indicated that they would have liked to receive the intervention earlier following diagnosis. CONCLUSIONS PEPA-RA and the outcomes appear feasible and acceptable. Overall, small beneficial effects were noted at 12 weeks for most outcomes. Challenges to recruitment resulted in a smaller than anticipated sample size, and the majority of participants were active at baseline indicating that future recruitment needs to target less active individuals.
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Affiliation(s)
- Fiona Cramp
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Rachel Thomas
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Anne M Haase
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,School for Policy Studies, University of Bristol, Bristol, UK.,School of Health, Victoria University of Wellington, PO Box 600, Wellington, 6140, New Zealand
| | - Melissa Domaille
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Sarah Manns
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Caroline Swales
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,Patient Research Partner, Bristol, UK
| | - Judy Hurfurt
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,Patient Research Partner, Bristol, UK
| | - Nicola E Walsh
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Pearson J, Whale K, Walsh NE, Derham S, Russell J, Cramp F. Fibromyalgia Self‐Management: Mapping the behaviour change techniques used in a practice‐based programme. Musculoskeletal Care 2020; 18:372-382. [PMID: 32452615 DOI: 10.1002/msc.1470] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Jennifer Pearson
- Centre for Health and Clinical Research, Faculty of Health and Applied SciencesUniversity of the West of England Bristol UK
- Brownsword Therapy CentreRoyal United Hospital Bath Bath UK
| | - Katie Whale
- National Institute for Health Research Bristol Biomedical Research CentreUniversity Hospitals Bristol NHS Foundation Trust and University of Bristol UK
| | - Nicola E Walsh
- Centre for Health and Clinical Research, Faculty of Health and Applied SciencesUniversity of the West of England Bristol UK
| | - Sandi Derham
- Brownsword Therapy CentreRoyal United Hospital Bath Bath UK
| | - Julie Russell
- Brownsword Therapy CentreRoyal United Hospital Bath Bath UK
| | - Fiona Cramp
- Centre for Health and Clinical Research, Faculty of Health and Applied SciencesUniversity of the West of England Bristol UK
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Salmon VE, Hewlett S, Walsh NE, Kirwan JR, Morris M, Urban M, Cramp F. Developing a group intervention to manage fatigue in rheumatoid arthritis through modifying physical activity. BMC Musculoskelet Disord 2019; 20:194. [PMID: 31054567 PMCID: PMC6500086 DOI: 10.1186/s12891-019-2558-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/09/2019] [Indexed: 11/19/2022] Open
Abstract
Background Fatigue is a major symptom of rheumatoid arthritis (RA). There is some evidence that physical activity (PA) may be effective in reducing RA fatigue. However, few PA interventions have been designed to manage fatigue and there is limited evidence of end-user input into intervention development. The aim of this research was to co-design an intervention to support self-management of RA fatigue through modifying PA. Methods A series of studies used mixed methodological approaches to co-design a fatigue management intervention focused on modifying PA based on UK Medical Research Council guidance, and informed by the Behaviour Change Wheel theoretical framework. Development was based on existing evidence, preferences of RA patients and rheumatology healthcare professionals, and practical issues regarding intervention format, content and implementation. Results The resulting group-based intervention consists of seven sessions delivered by a physiotherapist over 12 weeks. Each session includes an education and discussion session followed by supervised PA chosen by the participant. The intervention is designed to support modification and maintenance of PA as a means of managing fatigue. This is underpinned by evidence-based behaviour change techniques that might support changes in PA behaviour. Intervention delivery is interactive and aims to enhance capability, opportunity and motivation for PA. Conclusion This study outlines stages in the systematic development of a theory-based intervention designed through consultation with RA patients and healthcare professionals to reduce the impact of RA fatigue. The feasibility of future evaluation of the intervention should now be determined.
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Affiliation(s)
- Victoria E Salmon
- Institute of Health Research, University of Exeter College of Medicine and Health, College House, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Sarah Hewlett
- Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK.,Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin St, Bristol, BS2 8HW, UK
| | - Nicola E Walsh
- Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK
| | - John R Kirwan
- Academic Rheumatology, University of Bristol, University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK.,Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin St, Bristol, BS2 8HW, UK
| | - Maria Morris
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin St, Bristol, BS2 8HW, UK
| | - Marie Urban
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin St, Bristol, BS2 8HW, UK
| | - Fiona Cramp
- Faculty of Health & Applied Sciences, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK
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Abstract
BACKGROUND Osteoarthritis (OA) of the lower limb affects millions of people worldwide, and results in pain and reduced function. We reviewed guidelines and Cochrane reviews for physical therapy interventions to manage the condition. SOURCES OF DATA Evidence from meta-analyses and systematic reviews was included. We also identified the recommendations from guidelines relevant to practice in the UK. AREAS OF AGREEMENT There is strongest evidence to support the use of exercise to improve pain, function and quality of life. AREAS OF CONTROVERSY There is limited evidence to support the use of some commonly utilized physiotherapy interventions. National Institute for Health and Clinical Excellence do not recommend the use of acupuncture. GROWING POINTS Programmes that include single exercise type may be more beneficial than combined strengthening and aerobic interventions. AREAS TIMELY FOR DEVELOPING RESEARCH Further research is required to determine how to facilitate long-term engagement with exercise to sustain the beneficial effects on pain, function and quality of life. Studies that investigate packages of care, combining interventions require further investigation.
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Affiliation(s)
- Nicola E Walsh
- Centre for Health and Clinical Research, Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol BS16 1DD, UK
| | - Jennifer Pearson
- Centre for Health and Clinical Research, Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol BS16 1DD, UK
| | - Emma L Healey
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK
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Salmon VE, Hewlett S, Walsh NE, Kirwan JR, Cramp F. Physical activity interventions for fatigue in rheumatoid arthritis: a systematic review. Physical Therapy Reviews 2017. [DOI: 10.1080/10833196.2016.1277454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Victoria E. Salmon
- Institute of Health Research, University of Exeter Medical School , Exeter, UK
| | - Sarah Hewlett
- Faculty of Health and Applied Sciences, University of the West of England , Bristol, UK
| | - Nicola E. Walsh
- Faculty of Health and Applied Sciences, University of the West of England , Bristol, UK
| | - John R. Kirwan
- Academic Rheumatology, University of Bristol , Bristol, UK
| | - Fiona Cramp
- Faculty of Health and Applied Sciences, University of the West of England , Bristol, UK
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Withall J, Haase AM, Walsh NE, Young A, Cramp F. Physical activity engagement in early rheumatoid arthritis: a qualitative study to inform intervention development. Physiotherapy 2016; 102:264-71. [DOI: 10.1016/j.physio.2015.07.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 07/25/2015] [Indexed: 11/30/2022]
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Hurley DA, Murphy LC, Hayes D, Hall AM, Toomey E, McDonough SM, Lonsdale C, Walsh NE, Guerin S, Matthews J. Using intervention mapping to develop a theory-driven, group-based complex intervention to support self-management of osteoarthritis and low back pain (SOLAS). Implement Sci 2016; 11:56. [PMID: 27113575 PMCID: PMC4845501 DOI: 10.1186/s13012-016-0418-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 04/05/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Medical Research Council framework provides a useful general approach to designing and evaluating complex interventions, but does not provide detailed guidance on how to do this and there is little evidence of how this framework is applied in practice. This study describes the use of intervention mapping (IM) in the design of a theory-driven, group-based complex intervention to support self-management (SM) of patients with osteoarthritis (OA) and chronic low back pain (CLBP) in Ireland's primary care health system. METHODS The six steps of the IM protocol were systematically applied to develop the self-management of osteoarthritis and low back pain through activity and skills (SOLAS) intervention through adaptation of the Facilitating Activity and Self-management in Arthritis (FASA) intervention. A needs assessment including literature reviews, interviews with patients and physiotherapists and resource evaluation was completed to identify the programme goals, determinants of SM behaviour, consolidated definition of SM and required adaptations to FASA to meet health service and patient needs and the evidence. The resultant SOLAS intervention behavioural outcomes, performance and change objectives were specified and practical application methods selected, followed by organised programme, adoption, implementation and evaluation plans underpinned by behaviour change theory. RESULTS The SOLAS intervention consists of six weekly sessions of 90-min education and exercise designed to increase participants' physical activity level and use of evidence-based SM strategies (i.e. pain self-management, pain coping, healthy eating for weight management and specific exercise) through targeting of individual determinants of SM behaviour (knowledge, skills, self-efficacy, fear, catastrophizing, motivation, behavioural regulation), delivered by a trained physiotherapist to groups of up to eight individuals using a needs supportive interpersonal style based on self-determination theory. Strategies to support SOLAS intervention adoption and implementation included a consensus building workshop with physiotherapy stakeholders, development of a physiotherapist training programme and a pilot trial with physiotherapist and patient feedback. CONCLUSIONS The SOLAS intervention is currently being evaluated in a cluster randomised controlled feasibility trial. IM is a time-intensive collaborative process, but the range of methods and resultant high level of transparency is invaluable and allows replication by future complex intervention and trial developers.
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Affiliation(s)
- Deirdre A. Hurley
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin 4, Ireland
| | - Laura Currie Murphy
- Breast-Predict-Collaborative Cancer Research Centre, Pharmacology and Therapeutics, Trinity College Dublin, St James’s Hospital, Dublin 8, Ireland
| | - David Hayes
- UCD School of Psychology, University College Dublin, Dublin 4, Ireland
| | - Amanda M. Hall
- The George Institute for Global Health, Oxford Martin School, Oxford University, Oxford, UK
| | - Elaine Toomey
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin 4, Ireland
| | - Suzanne M. McDonough
- Institute of Nursing and Health Research, Jordanstown Campus, Ulster University, Antrim, BT37 0QB UK
| | - Chris Lonsdale
- Institute for Positive Psychology and Education, Faculty of Health Sciences, Australian Catholic University, 25A Barker Road, Strathfield, NSW 2135 Australia
| | - Nicola E. Walsh
- Faculty of Health and Applied Sciences, Glenside Campus, University of the West of England, Bristol, BS16 1DD UK
| | - Suzanne Guerin
- UCD School of Psychology, University College Dublin, Dublin 4, Ireland
| | - James Matthews
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin 4, Ireland
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Hurley DA, Hall AM, Currie-Murphy L, Pincus T, Kamper S, Maher C, McDonough SM, Lonsdale C, Walsh NE, Guerin S, Segurado R, Matthews J. Theory-driven group-based complex intervention to support self-management of osteoarthritis and low back pain in primary care physiotherapy: protocol for a cluster randomised controlled feasibility trial (SOLAS). BMJ Open 2016; 6:e010728. [PMID: 26801470 PMCID: PMC4735126 DOI: 10.1136/bmjopen-2015-010728] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION International clinical guidelines consistently endorse the promotion of self-management (SM), including physical activity for patients with chronic low back pain (CLBP) and osteoarthritis (OA). Patients frequently receive individual treatment and advice to self-manage from physiotherapists in primary care, but the successful implementation of a clinical and cost-effective group SM programme is a key priority for health service managers in Ireland to maximise long-term outcomes and efficient use of limited and costly resources. METHODS/ANALYSIS This protocol describes an assessor-blinded cluster randomised controlled feasibility trial of a group-based education and exercise intervention underpinned by self-determination theory designed to support an increase in SM behaviour in patients with CLBP and OA in primary care physiotherapy. The primary care clinic will be the unit of randomisation (cluster), with each clinic randomised to 1 of 2 groups providing the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) intervention or usual individual physiotherapy. Patients are followed up at 6 weeks, 2 and 6 months. The primary outcomes are the (1) acceptability and demand of the intervention to patients and physiotherapists, (2) feasibility and optimal study design/procedures and sample size for a definitive trial. Secondary outcomes include exploratory analyses of: point estimates, 95% CIs, change scores and effect sizes in physical function, pain and disability outcomes; process of change in target SM behaviours and selected mediators; and the cost of the intervention to inform a definitive trial. ETHICS/DISSEMINATION This feasibility trial protocol was approved by the UCD Human Research Ethics-Sciences Committee (LS-13-54 Currie-Hurley) and research access has been granted by the Health Services Executive Primary Care Research Committee in January 2014. The study findings will be disseminated to the research, clinical and health service communities through publication in peer-reviewed journals, presentation at national and international academic and clinical conferences. TRIAL REGISTRATION NUMBER ISRCTN 49875385; Pre-results.
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Affiliation(s)
- Deirdre A Hurley
- Institute for Sport and Health and UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Amanda M Hall
- The George Institute for Global Health, Oxford Martin School, Oxford University, Oxford, UK
| | - Laura Currie-Murphy
- Breast-Predict—Collaborative Cancer Research Centre, Pharmacology and Therapeutics, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | - Tamar Pincus
- Department of Psychology, University of London, Royal Holloway, London, UK
| | - Steve Kamper
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Chris Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne M McDonough
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Chris Lonsdale
- Institute for Positive Psychology and Education, Faculty of Health Sciences, Australian Catholic University, New South Wales, Australia
| | - Nicola E Walsh
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Suzanne Guerin
- UCD School of Psychology, University College Dublin, Dublin, Ireland
| | - Ricardo Segurado
- CSTAR and UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - James Matthews
- Institute for Sport and Health and UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
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Hurley MV, Walsh NE, Mitchell H, Nicholas J, Patel A. Long-term outcomes and costs of an integrated rehabilitation program for chronic knee pain: a pragmatic, cluster randomized, controlled trial. Arthritis Care Res (Hoboken) 2012; 64:238-47. [PMID: 21954131 DOI: 10.1002/acr.20642] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Chronic joint pain is a major cause of pain and disability. Exercise and self-management have short-term benefits, but few studies follow participants for more than 6 months. We investigated the long-term (up to 30 months) clinical and cost effectiveness of a rehabilitation program combining self-management and exercise: Enabling Self-Management and Coping of Arthritic Knee Pain Through Exercise (ESCAPE-knee pain). METHODS In this pragmatic, cluster randomized, controlled trial, 418 people with chronic knee pain (recruited from 54 primary care surgeries) were randomized to usual care (pragmatic control) or the ESCAPE-knee pain program. The primary outcome was physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function), with a clinically meaningful improvement in physical function defined as a ≥15% change from baseline. Secondary outcomes included pain, psychosocial and physiologic variables, costs, and cost effectiveness. RESULTS Compared to usual care, ESCAPE-knee pain participants had large initial improvements in function (mean difference in WOMAC function -5.5; 95% confidence interval [95% CI] -7.8, -3.2). These improvements declined over time, but 30 months after completing the program, ESCAPE-knee pain participants still had better physical function (difference in WOMAC function -2.8; 95% CI -5.3, -0.2); lower community-based health care costs (£-47; 95% CI £-94, £-7), medication costs (£-16; 95% CI £-29, £-3), and total health and social care costs (£-1,118; 95% CI £-2,566, £-221); and a high probability (80-100%) of being cost effective. CONCLUSION Clinical and cost benefits of ESCAPE-knee pain were still evident 30 months after completing the program. ESCAPE-knee pain is a more effective and efficient model of care that could substantially improve the health, well-being, and independence of many people, while reducing health care costs.
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Affiliation(s)
- M V Hurley
- St Georges University of London and Kingston University, London, UK.
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Abstract
BACKGROUND Chronic hip pain is prevalent and disabling and has considerable consequences for the individual, and health and social care. Evidence-based guidelines recommend that patients with chronic hip pain benefit from exercise, but these guidelines are predominantly based on the efficacy of knee rehabilitation programmes. Studies investigating hip rehabilitation programmes suggest that these may not be feasible, citing issues with case identification. This study evaluated the feasibility of an exercise-based rehabilitation programme in a primary care hospital. METHODS Forty-eight participants with chronic hip pain were randomly allocated to receive a five-week exercise and self-management programme or to continue under the management of their general practitioner (GP). Participants were assessed at baseline, six weeks and six months. Outcome measures included Western Ontario and McMaster Universities osteoarthritis index physical function subscale, pain, objective functional performance, self-efficacy, anxiety and depression. RESULTS This programme was feasible, well tolerated and easily implemented into a primary healthcare facility. Adherence to the programme was high (81% attendance). Immediately following rehabilitation, all outcomes measures improved (effect sizes 0.2-0.4), although these improvements diminished at six months. There were no differences between the groups (all p > 0.05). CONCLUSIONS An exercise-based rehabilitation programme was found to be feasible and well tolerated by people with chronic hip pain. The moderate effects in all outcomes immediately following rehabilitation suggested that it warrants further investigation. Issues with diagnosis and adaptations to the programme were identified and will be addressed in a randomized controlled trial.
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Jessep SA, Walsh NE, Ratcliffe J, Hurley MV. Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain. Physiotherapy 2009; 95:94-102. [PMID: 19627690 DOI: 10.1016/j.physio.2009.01.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Accepted: 01/05/2009] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chronic knee pain is a major cause of disability in the elderly. Management guidelines recommend exercise and self-management interventions as effective treatments. The authors previously described a rehabilitation programme integrating exercise and self-management [Enabling Self-management and Coping with Arthritic knee Pain through Exercise (ESCAPE-knee pain)] that produced short-term improvements in pain and physical function, but sustaining these improvements is difficult. Moreover, the programme is untried in clinical environments, where it would ultimately be delivered. OBJECTIVES To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy. DESIGN Pragmatic, randomised controlled trial. SETTING Outpatient physiotherapy department and community centre. PARTICIPANTS Sixty-four people with chronic knee pain. INTERVENTIONS Outpatient physiotherapy compared with ESCAPE-knee pain. OUTCOMES The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index. Secondary outcomes included pain, objective functional performance, anxiety, depression, exercise-related health beliefs and healthcare utilisation. All outcomes were assessed at baseline and 12 months after completing the interventions (primary endpoint). ANCOVA investigated between-group differences. RESULTS Both groups demonstrated similar improvements in clinical outcomes. Outpatient physiotherapy cost pound 130 per person and the healthcare utilisation costs of participants over 1 year were pound 583. The ESCAPE-knee pain programme cost pound 64 per person and the healthcare utilisation costs of participants over 1 year were pound 320. CONCLUSIONS ESCAPE-knee pain can be delivered as a community-based integrated rehabilitation programme for people with chronic knee pain. Both ESCAPE-knee pain and outpatient physiotherapy produced sustained physical and psychosocial benefits, but ESCAPE-knee pain cost less and was more cost-effective.
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Affiliation(s)
- Sally A Jessep
- Physiotherapy Department, Sevenoaks Hospital, West Kent Primary Care Trust, Sevenoaks TN13 3PG, UK
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Abstract
OBJECTIVES To document physiotherapy provision for patients with knee osteoarthritis (OA) in relation to the United Kingdom (UK) recently published National Institute of health and Clinical Excellence (NICE) guidelines for osteoarthritis. DESIGN Questionnaire survey of chartered physiotherapists. METHOD 300 postal questionnaires were distributed to Physiotherapy Departments requesting information regarding source of referrals, treatment aims, preferred methods of treatment and service delivery. RESULTS Responses were received from 83 physiotherapists (28 %), predominantly working in the UK National Health Service. Approximately equal numbers of referrals came from primary and secondary care. Aims of physiotherapy management were to; encourage self-management; increase strength and range of movement; reduce pain; and improve function. To achieve these, exercise was utilised by 100% of practitioners, often supplemented with electrotherapeutic modalities (66%), manual therapy (64%) and acupuncture (60%). The majority of patients received individual treatment for a total contact time of 1-2 hours, whilst most group interventions lasted 5-6 hours. Approximately half (54%) of respondents reported using outcome measures to determine treatment efficacy. CONCLUSIONS Although knee OA is usually managed in primary care, the similar number of referrals from primary and secondary care may suggest a deviation from evidence-based management guidelines. The guidelines' recommendations of exercise, patient education and self-management are observed by physiotherapists, but other modalities are often used despite poor or no research evidence supporting their efficacy. Whether any of these interventions are clinically beneficial is speculative as treatment outcomes were frequently under-evaluated.
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Affiliation(s)
- Nicola E Walsh
- School of Allied Health Professions, Glenside Campus, University of the West of England, Blackberry Hill, Bristol, BS16 1DD, UK.
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Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Williamson E, Jones RH, Reeves BC, Dieppe PA, Patel A. Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain. ACTA ACUST UNITED AC 2007; 57:1220-9. [PMID: 17907207 PMCID: PMC2675012 DOI: 10.1002/art.23011] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program. METHODS Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness. RESULTS Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost 224 pounds (95% confidence interval [95% CI] 184 pounds, 262 pounds) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay 1,900 pounds for improvements in functioning. Indiv-rehab cost 314 pounds/person and Grp-rehab 125 pounds/person. Indiv-rehab cost 189 pounds (95% CI 168 pounds, 208 pounds) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP 5,500 pounds. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome. CONCLUSION Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.
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Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Patel A, Williamson E, Jones RH, Dieppe PA, Reeves BC. Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial. ACTA ACUST UNITED AC 2007; 57:1211-9. [PMID: 17907147 PMCID: PMC2673355 DOI: 10.1002/art.22995] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies (Enabling Self-management and Coping with Arthritic Knee Pain through Exercise [ESCAPE-knee pain]) with usual primary care in improving functioning in persons with chronic knee pain. METHODS We conducted a single-blind, pragmatic, cluster randomized controlled trial. Participants age >/=50 years, reporting knee pain for >6 months, were recruited from 54 inner-city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self-reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC-func]) 6 months after completing rehabilitation. RESULTS A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (-3.33 difference in WOMAC-func score; 95% confidence interval [95% CI] -5.88, -0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (-3.53; 95% CI -6.52, -0.55) or group rehabilitation (-3.16; 95% CI -6.55, -0.12). CONCLUSION ESCAPE-knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.
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Abstract
OBJECTIVE To develop core recommendations for the learning outcomes of an undergraduate curriculum in musculoskeletal conditions for any parts of the globe. METHODS Recommendations were developed by wide consultation with experts in orthopaedics, rheumatology, osteoporosis, and rehabilitation from all parts of the world who had interest and experience in these specialties, with the support of international and national societies. All possible knowledge, skills, and attitudes that might be of relevance to musculoskeletal conditions were initially considered and then reduced to those considered essential for all doctors. RESULTS The recommendations focus on (a) basic skills to assess and diagnose musculoskeletal problems; (b) the competency to assess specific common or urgent musculoskeletal problems; (c) the theoretical background of the conditions and their management; and (d) the core knowledge necessary to support diagnosis and management, including basic sciences. At the end of the course, all students should be able to differentiate normal from abnormal locomotor symptoms in a patient, determine the relevant investigations and interpret the results, formulate a limited differential diagnosis, recognise the impact of the problem on the individual patient, and make an appropriate management plan. CONCLUSIONS The recommendations set global standards for the minimum level of competence in managing patients with musculoskeletal problems. They define what all doctors should know when graduating from medical school, regardless of further specialisation. They are intended to form the basis of a curriculum for a musculoskeletal course and can be adapted for any medical school in any country throughout the world.
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Affiliation(s)
- A D Woolf
- Institute of Health and Social Care, Peninsula Medical School, Rheumatology Unit, Royal Cornwall Hospital, Truro TR1 3LJ, UK.
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Abstract
BACKGROUND AND OBJECTIVE A low cost laser imager was designed and fabricated for measurement of wound geometry. METHODS The accuracy of the imager was validated using reference depressions of known dimensions. Perimeter, area, and volume were compared to planimetric and packing techniques on simulated wound models. RESULTS Wound tracing and alginate measurement methods required approximately 20 times longer for the reference standards, and 11 times longer for the simulated wounds than with the laser scanning method (LSM). LSM consistently overestimated the reference perimeter by 0.73+/-0.20 cm and the area by 0.98+/-0.62 cm2. Volume estimates were not statistically different. The tracing method underestimated the perimeter by 0.34+/-0.27 cm and the area by 1.07+/-1.09 cm2. Volume measurements by the alginate method were not statistically different. The perimeters of the simulated wounds averaged 1.29+/-0.27 cm greater using the LSM than obtained by the tracing method, and areas greater by 2.02+/-1.30 cm2. Volume scans averaged 1.04+/-0.61 cm3 greater than by the alginate method.
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Affiliation(s)
- R B Smith
- Department of Anesthesiology, The University of Texas Health Sciences Center at San Antonio, 78284, USA
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Hollinshead WH, Vigliani MB, Walsh NE, LeClair CA, Zelano LA. Assessing and responding to pre/periconception risks--early experience with the Rhode Island Women's Health Screening & Referral Program. Med Health R I 2000; 83:136-9. [PMID: 10874814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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McAnelly RD, Refaeian M, O'Connell DG, Powell GD, Walsh NE. Successful prosthetic fitting of a 73-year-old hip disarticulation amputee patient with cardiopulmonary disease. Arch Phys Med Rehabil 1998; 79:585-8. [PMID: 9596404 DOI: 10.1016/s0003-9993(98)90078-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with hip disarticulation (HD) require high energy expenditure for successful prosthetic ambulation. Thus, older patients are rarely fitted with an HD prosthesis. To our knowledge there are no reports of gait analysis following successful prosthetic fitting of an elderly HD amputee patient with systemic cardiopulmonary disease. We report the case of successful prosthetic ambulation in a 73-year-old man with HD secondary to histiosarcoma and a medical history significant for stable angina, chronic obstructive pulmonary disease, and diabetes mellitus. The patient underwent gait training with an endoskeletal prosthesis and achieved ambulation to 400 feet with bilateral forearm crutches. Vicon kinematic gait analysis revealed a cadence of 44 steps/min (112 steps/min normal), and double support time of 47% (26% normal). Oxygen rate during ambulation (VO2) was 11.0 mL/kg/min at velocity of .35 m/sec, compared with published figures for ambulation in those with HD of 10.73 mL/kg/min at velocity of .93 m/sec. At 1-year follow-up, the patient continued to walk into church with the prosthesis. We conclude that a trial fitting of an HD prosthesis should be considered on an individual basis in elderly amputee patients.
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Affiliation(s)
- R D McAnelly
- Department of Rehabilitation Medicine, University of Texas Health Science Center, and Warm Springs and Baptist Rehabilitation Hosptial, San Antonio 78284-7798, USA
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Hogan PF, Dobson A, Haynie B, DeLisa JA, Gans B, Grabois M, LaBan MM, Melvin JL, Walsh NE. Physical medicine and rehabilitation workforce study: the supply of and demand for physiatrists. Arch Phys Med Rehabil 1996; 77:95-9. [PMID: 8554483 DOI: 10.1016/s0003-9993(96)90228-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Analysis, results, and implications of a supply and demand workforce model for physical medicine and rehabilitation. Explicit issues addressed include: (1) the supply implications of maintaining current (1994-1995) output of physiatrists from residency programs; (2) the implications of continued growth in managed care on the demand for the services of physiatrists; (3) likely future supply and demand conditions; and (4) strategies to adapt to future conditions. DESIGN A workforce model of the supply and demand for physiatrists was developed. Parameters of the model are estimated using econometric models and by applying the judgments of a consensus panel. The model evaluated several different scenarios regarding managed care growth, competition from other providers and other factors. RESULTS Based on the analysis, physiatrists will continue to be in excess demand through the year 2000. More aggressive growth in managed care can affect this result. CONCLUSIONS Based on an overall assessment of supply and demand conditions, and under the assumption that the supply of new entrants each year remains in the range of 1994-1995 levels, demand for physiatrists will continue to exceed supply, on average, through the year 2000. Excess supply has, and will, emerge in selected geographic areas. If the profession is successful in informing the market regarding the advantages of physiatry, the profession can continue to grow without experiencing excess supply, in the aggregate, for the foreseeable future.
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Abstract
This study was designed to determine the effect of multimodal intervention and the prevention of back injury, and to evaluate the adverse side effects of using a lumbosacral corset in the workplace. Subjects were 90 male warehouse workers randomly selected from over 800 employees at a grocery distribution center. Subjects were assigned to three groups: true controls, no back school, no brace orthoses; back school only; and back school plus wearing a custom molded lumbosacral orthosis. Comparisons of pre-testing and 6-month follow-up post-testing for abdominal strength, cognitive data, work injury incidence and productivity and use of health care services were evaluated. Controls and training-only group showed no changes in strength productivity or lost time. Orthoses and training-group showed no changes in strength productivity or accident rate; however, they showed substantially less lost time. This study supports the concept of using education and prophylactic bracing to prevent back injury and reduce time loss. It appears that the use of intermittent prophylactic bracing has no adverse affects on abdominal muscle strength and may contribute to decreased lost time from work injuries.
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Affiliation(s)
- N E Walsh
- Department of Rehabilitation Medicine University of Texas Health Science Center, San Antonio 78284
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Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med 1990; 322:1627-34. [PMID: 2140432 DOI: 10.1056/nejm199006073222303] [Citation(s) in RCA: 396] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A number of treatments are widely prescribed for chronic back pain, but few have been rigorously evaluated. We examined the effectiveness of transcutaneous electrical nerve stimulation (TENS), a program of stretching exercises, or a combination of both for low back pain. Patients with chronic low back pain (median duration, 4.1 years) were randomly assigned to receive daily treatment with TENS (n = 36), sham TENS (n = 36), TENS plus a program of exercises (n = 37), or sham TENS plus exercises (n = 36). After one month no clinically or statistically significant treatment effect of TENS was found on any of 11 indicators of outcome measuring pain, function, and back flexion; there was no interactive effect of TENS with exercise. Overall improvement in pain indicators was 47 percent with TENS and 42 percent with sham TENS (P not significant). The 95 percent confidence intervals for group differences excluded a major clinical benefit of TENS for most outcomes. By contrast, after one month patients in the exercise groups had significant improvement in self-rated pain scores, reduction in the frequency of pain, and greater levels of activity as compared with patients in the groups that did not exercise. The mean reported improvement in pain scores was 52 percent in the exercise groups and 37 percent in the nonexercise groups (P = 0.02). Two months after the active intervention, however, most patients had discontinued the exercises, and the initial improvements were gone. We conclude that for patients with chronic low back pain, treatment with TENS is no more effective than treatment with a placebo, and TENS adds no apparent benefit to that of exercise alone.
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Affiliation(s)
- R A Deyo
- Health Services Research and Development, Seattle Veterans Affairs Medical Center, WA 98108
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Deyo RA, Walsh NE, Schoenfeld LS, Ramamurthy S. Can trials of physical treatments be blinded? The example of transcutaneous electrical nerve stimulation for chronic pain. Am J Phys Med Rehabil 1990; 69:6-10. [PMID: 2137345 DOI: 10.1097/00002060-199002000-00003] [Citation(s) in RCA: 122] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Therapeutic trials often attempt to "blind" patient and investigator to the true nature of treatments received, reducing the influences of conscious or subconscious prejudices. In drug trials, this is accomplished with placebo tablets, but blinding in trials of physical treatments is more problematic. This issue arose in a clinical trial of transcutaneous electrical nerve stimulation (TENS) for patients with chronic low back pain. Several study design features were incorporated to promote blinding: use of sham TENS units visually identical with real units, exclusion of potential subjects with previous TENS experience, avoidance of a crossover design and use of identical visit frequency, instructions and modifications in electrode placement. Subjects were asked not to discuss treatments with the clinicians who performed outcome assessments. Both patients and clinicians were asked to guess actual treatment assignments at the trial's end. Every patient in the true TENS group believed the unit was functioning properly, but the degree of certainty varied. In the sham TENS group, 84% also believed they had functioning units, but their certainty was significantly less than in the active treatment group. Differences in patient perceptions did not affect compliance, as the two groups had similar dropout rates, appointment compliance, days of TENS use and daily duration of TENS use. Clinicians guessed treatments correctly 61% of the time (as opposed to 50% expected by chance), again suggesting partial success in blinding. These efforts at blinding may partly explain the negative trial results for TENS efficacy. We conclude that complete blinding is difficult to achieve because of sensory difference in treatment and unintended communication between patient and examiner.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R A Deyo
- Health Services Research and Development, Seattle VA Medical Center, WA 98108
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Abstract
Diagnostic epidural blocks were performed on 27 chronic pain patients sequentially using saline, fentanyl, and lidocaine solution. The patients were divided into one of four groups based on their response to the epidural solutions: placebo response group--pain relief with placebo solutions; fentanyl response group--pain relief with epidural fentanyl; lidocaine response group (LRG)--pain relief with lidocaine but not fentanyl; and no response group--no pain relief with any of the solutions used. The four groups were compared on the basis of age, sex, site of pain, duration of pain, narcotic use, pain assessment index, and workmen's compensation claims. The comparisons resulted in the conclusion that LRG patients had a much longer average duration of pain than the other groups. On the basis of the information gathered, it was theorized that, despite their response to epidural lidocaine, LRG patients may actually be a group of operant pain patients. Their failure to receive analgesia from epidural fentanyl may be a learned response such that they associate any sensory input from the affected area as painful. If follow-up studies support these findings, then the diagnostic opioid technique may be a more sensitive tool in diagnosing chronic pain.
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Affiliation(s)
- J S Ellis
- Department of Anesthesiology, Wilford Hall Air Force Medical Center, Lackland Air Force Base, San Antonio, Texas
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Dumitru D, Walsh NE, Ramamurthy S. The premotor potential. Arch Phys Med Rehabil 1989; 70:537-40. [PMID: 2742470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A small waveform precedes the compound muscle action potential evoked from the thenar eminence with median nerve stimulation with high amplifier gains. This potential is believed to emanate from fibers destined to innervate the volar aspect of the first digit. It has been suggested recently that the source of the premotor potential is the palmar cutaneous branch of the median nerve. In this study, the palmar cutaneous branch of the median nerve was blocked at the wrist. A localized zone of anesthesia was observed over the proximal midpalm, not the thenar eminence, and the premotor response remained unchanged as did a midpalmar potential. The median nerve was then blocked at the base of the thenar eminence; only then did the premotor potential disappear. The palmar cutaneous branch of the median nerve innervates only a small portion of the medial aspect of the thenar eminence and does not produce the thenar premotor potential. Additionally, because of the close proximity of the main median nerve to its palmar cutaneous branch, volume conduction of stimuli and responses precludes an electrophysiologic technique which exclusively localizes the palmar cutaneous branch of the median nerve.
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Affiliation(s)
- D Dumitru
- Department of PM&R, University of Texas Health Science Center, San Antonio 78284-7798
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Abstract
This study compared the use of phenol and cryogenic blocks for neurolysis in 28 patients. Patients were assigned randomly to receive peripheral nerve blocks with either phenol or cryoanalgesia. Significantly more patients in the phenol group received 20% or greater relief at 2, 12, and 24 wk than patients in the cryogenic group. Only 27% of patients received significant relief, however, indicating that neurolytic blocks were not particularly effective even though local anesthetic blocks produced significant but temporary pain relief.
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Deyo RA, Walsh NE, Schoenfeld LS, Ramamurthy S. Studies of the Modified Somatic Perceptions Questionnaire (MSPQ) in patients with back pain. Psychometric and predictive properties. Spine (Phila Pa 1976) 1989; 14:507-10. [PMID: 2524889 DOI: 10.1097/00007632-198905000-00006] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The Modified Somatic Perceptions Questionnaire (MSPQ) was designed to measure heightened somatic awareness among patients with chronic pain. It was hoped that this questionnaire would help predict therapeutic responses for back pain patients. The reliability, validity, and predictive characteristics of this scale were tested among 97 patients with chronic low-back pain enrolled in a clinical trial of transcutaneous nerve stimulation and stretching exercises. Internal consistency was good (alpha = 0.78), and correlations with the Zung depression scale and certain MMPI scales were significant. Correlations with a baseline functional scale (the Sickness Impact Profile) were stronger than those with the MMPI. Unfortunately, the MSPQ did not correlate with functional outcomes, and was only weakly associated with pain outcomes. Thus, the MSPQ appears to be reliable and valid, but the somatic perceptions it measures may have little relation to patient outcomes.
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Affiliation(s)
- R A Deyo
- Multipurpose Arthritis Center, University of Texas Health Science Center, San Antonio
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Abstract
The cold pressor test elicits an emotional/motivational pain experience from the immersion of a limb in cold water. It has been widely used to evaluate (experimental and chronic) pain. However, normative models for quantification and comparison for pain tolerance have not previously been established. This study developed a normative mathematical model for pain tolerance using the cold pressor test with over 600 subjects. Norms for age, sex, and ethnic group were calculated. In addition, chronic pain patients were compared with pain-free patients to determine normative differences in response. The results indicate that at any given age Anglo-Saxon males have the longest tolerance time followed by non-Anglo-Saxon males, Anglo-Saxon females, and finally non-Anglo-Saxon females. There is a consistent decrease in tolerance time as the male age increases and minimal change in tolerance time as the female age increases. Chronic pain patients exhibited the same type of pain response pattern as healthy volunteers when corrected for age, sex, and ethnocultural subgroup.
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Affiliation(s)
- N E Walsh
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, San Antonio 78284-7798
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Greer DM, Morris J, Walsh NE, Glenn AM, Keppler J. Cost-effectiveness and efficacy of air-fluidized therapy in the treatment of pressure ulcers. J Enterostomal Ther 1988; 15:247-51. [PMID: 3060503 DOI: 10.1097/00152192-198811000-00028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
Facial nerve paralysis is the most common mononeuropathy and idiopathic facial paralysis (Bell's palsy) the most common seventh nerve disease electromyographers may be asked to evaluate. The electrophysiologic method of choice to assess the facial nerve is side-to-side evoked amplitude comparison with the affected side expressed as a percentage of the nonaffected side. This examination should be performed on days 3, 5, 7, 9, 11 and 13 after onset of paralysis. If the percentage of surviving axons falls below 10% within the first 14 days, an incomplete recovery is suggested. Electromyography may assist in prognosticating a functional return, determining neural conduction across the site of injury and following reinervation in the recovery period. The persistence or early return of an absent R1 component of the blink reflex may qualitatively suggest a satisfactory functional outcome in facial paralysis. Supramaximally exciting the facial nerve at the stylomastoid foramen and comparing the clinical response on the affected and nonaffected side, maximum stimulation test, can also predict eventual seventh nerve return. Observing a minimal twitch, utilizing the nerve excitability test or measuring the facial nerve latency have yielded poor correlations with functional return and are of limited usefulness in the prognostication of acute facial palsies. Trigeminal somatosensory evoked potentials can be employed to evaluate the status of the trigeminal nerve as approximately 50% of patients with Bell's palsy also have lesions involving the fifth nerve. Side-to-side amplitude comparison and electromyography are the two most valuable electrophysiologic methods of assessing facial nerve functioning.
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Affiliation(s)
- D Dumitru
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, San Antonio 78284-7798
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Abstract
A thorough comprehension of electrodiagnostic equipment is essential to consistently obtain accurate and reproducible data. Unreliable waveform latencies or morphologies may result from inappropriate filter settings, sensitivity comparisons, sweep speeds, interelectrode separation, cathode/anode reversals and stimulus artifact. A low frequency filter with too high a frequency limit may decrease amplitude, shorten peak latency, decrease the negative spike duration, add a phase and increase total waveform duration. A high frequency filter with too low a cut-off may decrease amplitude and prolong onset and peak latencies. Increasing the amplifier's sensitivity may shorten the onset latency of a response. Sweep speeds that are too slow may omit phases, turns or entire potentials when using digital equipment. If the interelectrode separation is inadequate, waveform morphology and amplitude can be altered. Reversing cathode and anode placement affects latency and velocity determinations. Stimulus artifact may obscure a response and its reduction must be understood. Comparing latencies and amplitudes at different instrument settings is never appropriate and can lead to serious errors and misdiagnoses. A naive approach to instrumentation, therefore, is indefensible.
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Affiliation(s)
- D Dumitru
- Dept. of Physical Medicine and Rehabilitation, University of Texas Health Sciences Center, San Antonio 78284-7798
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Deyo RA, Bass JE, Walsh NE, Schoenfeld LS, Ramamurthy S. Prognostic variability among chronic pain patients: implications for study design, interpretation, and reporting. Arch Phys Med Rehabil 1988; 69:174-8. [PMID: 2964814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Chronic pain patients share many characteristics, but there is important prognostic variability among them. By selecting for certain characteristics, different recruitment methods and entry criteria for clinical or research programs may influence the likelihood of success regardless of treatment efficacy. This was demonstrated when subjects (n = 55) were recruited through lay publicity for a clinical trial of therapy for chronic back pain. In comparison to routine pain clinic patients (n=61), subjects in the clinical trial were better educated, were more often employed, had more favorable personality profiles, and were less likely to have had surgery or narcotic use (all p less than 0.004). Pain relief was significantly better for clinical trial subjects, apparently due to baseline prognostic differences rather than uniquely efficacious therapy. We conclude that chronic pain patients vary in prognostically important ways; that recruitment methods and criteria strongly influence these characteristics; and that greater attention to these details is needed when interpreting and reporting clinical research.
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Affiliation(s)
- R A Deyo
- Multipurpose Arthritis Center, University of Texas Health Science Center, San Antonio 78284
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Walsh NE, Dumitru D. The influence of compensation on recovery from low back pain. Occup Med 1988; 3:109-21. [PMID: 2963384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The influence of financial compensation on recovery is one of the most controversial issues in the treatment of low back pain. In this review the authors include psychological aspects of compensation and the effects of compensation on injury rate, injury duration, and rehabilitation outcomes.
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Affiliation(s)
- N E Walsh
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, San Antonio 78284-7798
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Dumitru D, Walsh NE, Weber CF. Electrophysiologic study of the Riche-Cannieu anomaly. Electromyogr Clin Neurophysiol 1988; 28:27-31. [PMID: 3168913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Walsh NE, Dumitru D, Kalantri A, Roman AM. Brachial neuritis involving the bilateral phrenic nerves. Arch Phys Med Rehabil 1987; 68:46-8. [PMID: 3800625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Brachial neuritis with bilateral hemidiaphragmatic paralysis has been reported in two previous cases in the literature. We report a patient who experienced severe right shoulder discomfort three weeks prior to hospital admission which evolved to include both shoulders. Two weeks prior to admission he noticed the onset of discomfort in breathing in the supine position and shortness of breath with minor exertion. The admitting diagnoses were myocardial infarction due to significant ECG changes and idiopathic elevated bilateral hemidiaphragms. The patient had findings significant for tachypnea, dyspnea, decreased breath sounds at the bases bilaterally, impaired motion of the bilateral lung bases on inspiration and paradoxical respirations. Comprehensive medical testing and evaluation revealed bilateral elevated hemidiaphragms and vital capacity 40% of normal. Weakness of the proximal shoulder girdle and bicep musculature bilaterally was noted. Electromyography was significant for reduced recruitment pattern in the bilateral shoulder girdle musculature. Nerve conduction studies suggested bilateral phrenic neuropathy. This case is an unusual presentation of brachial neuritis affecting the bilateral shoulder girdle with phrenic nerve involvement. The differential diagnosis of acute shoulder pain associated with respiratory symptomatology should therefore include brachial neuritis.
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Walsh NE, Ramamurthy S, Schoenfeld L, Hoffman J. Analgesic effectiveness of D-phenylalanine in chronic pain patients. Arch Phys Med Rehabil 1986; 67:436-9. [PMID: 3524509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Enkephalins are a biochemical pathway for endogenous analgesia. A number of compounds inhibit degradation of enkephalins within the body. One of these compounds, D-phenylalanine (DPA), has been shown to increase the pain threshold in animals. It is hypothesized that this naloxone reversible analgesia is induced by DPA blockage of enkephalin degradation by the enzyme carboxypeptidase A. Preliminary studies of chronic pain patients have shown a response rate to DPA from 32% to 75%. This study was a double-blind crossover evaluation of a randomized parallel design to determine the efficacy of DPA in 30 subjects with chronic pain from varied etiology which was unrelieved by multiple therapeutic interventions. Each patient received a stabilized therapeutic regimen during this study consisting of four weeks of either DPA 250 mg or lactose (placebo) orally four times a day. After four weeks the DPA and placebo groups were crossed over for an additional four weeks of treatment. Pain was quantified using a visual analog pain scale and a cold pressor test. Data from the pain questionnaires revealed more pain relief on DPA reported by 25% of the patients, more pain relief on placebo reported by 22% of the patients, and no difference in pain relief reported by 53% of the patients. Lowest pain level of the visual analog scale was reported by 47% of the patients on DPA and 53% on placebo. There appears to be no significant analgesic effect from D-phenylalanine in chronic pain patients when compared to placebo.
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Schoenfeld LS, Walsh NE, Ramamurthy S. Electrosleep and chronic pain. J Pain Symptom Manage 1986; 1:151-5. [PMID: 2945872 DOI: 10.1016/s0885-3924(86)80064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Tager IB, Ginsberg MB, Ellis SE, Walsh NE, Dupont I, Simchen E, Faich GA. An epidemiologic study of the risks associated with peripheral intravenous catheters. Am J Epidemiol 1983; 118:839-51. [PMID: 6650485 DOI: 10.1093/oxfordjournals.aje.a113702] [Citation(s) in RCA: 138] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
As part of a standardized, multi-hospital prospective surveillance system for nosocomial infections in Rhode Island, an analysis was undertaken in March 1980-February 1982 to determine the interplay of factors that contribute to the risk of phlebitis in peripheral, non-steel, non-butterfly intravenous catheters. The authors studied 3094 patients with 5161 total episodes of peripheral intravenous catheters from day of admission until day of discharge. The overall rate of phlebitis was 2.3% (118 episodes), and the rate of intravenous catheter-associated bacteremia was 0.08% (1 definite episode, 3 possible episodes). Factors significantly associated with the occurrence of phlebitis were: underlying risk for any nosocomial infection, duration of the catheter episode, chronological order of the episode and an interaction between the latter two variables. Analysis of day-specific risk of phlebitis indicated that, for patients with low risk diagnoses, initial peripheral intravenous catheters might be left in place with relative safety for up to 96 hours. Over this time period, the day-specific risk for such patients ranged between 0.8% and 1.4%, exclusive of the first day. In all other circumstances, the current recommendation of 48-72 hours seems appropriate.
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