Information technologies for pain management

Millions of people around the world suffer from pain, acute or chronic and this raises the importance of its screening, assessment and treatment. The importance of pain is attested by the fact that it is considered the fifth vital sign for indicating basic bodily functions, health and quality of life, together with the four other vital signs: blood pressure, body temperature, pulse rate and respiratory rate. However, while these four signals represent an objective physical parameter, the occurrence of pain expresses an emotional status that happens inside the mind of each individual and therefore, is highly subjective that makes difficult its management and evaluation. For this reason, the self-report of pain is considered the most accurate pain assessment method wherein patients should be asked to periodically rate their pain severity and related symptoms. Thus, in the last years computerised systems based on mobile and web technologies are becoming increasingly used to enable patients to report their pain which lead to the development of electronic pain diaries (ED). This approach may provide to health care professionals (HCP) and patients the ability to interact with the system anywhere and at anytime thoroughly changes the coordinates of time and place and offers invaluable opportunities to the healthcare delivery. However, most of these systems were designed to interact directly to patients without presence of a healthcare professional or without evidence of reliability and accuracy. In fact, the observation of the existing systems revealed lack of integration with mobile devices, limited use of web-based interfaces and reduced interaction with patients in terms of obtaining and viewing information. In addition, the reliability and accuracy of computerised systems for pain management are rarely proved or their effects on HCP and patients outcomes remain understudied. This thesis is focused on technology for pain management and aims to propose a monitoring system which includes ubiquitous interfaces specifically oriented to either patients or HCP using mobile devices and Internet so as to allow decisions based on the knowledge obtained from the analysis of the collected data. With the interoperability and cloud computing technologies in mind this system uses web services (WS) to manage data which are stored in a Personal Health Record (PHR). A Randomised Controlled Trial (RCT) was implemented so as to determine the effectiveness of the proposed computerised monitoring system. The six weeks RCT evidenced the advantages provided by the ubiquitous access to HCP and patients so as to they were able to interact with the system anywhere and at anytime using WS to send and receive data. In addition, the collected data were stored in a PHR which offers integrity and security as well as permanent on line accessibility to both patients and HCP. The study evidenced not only that the majority of participants recommend the system, but also that they recognize it suitability for pain management without the requirement of advanced skills or experienced users. Furthermore, the system enabled the definition and management of patient-oriented treatments with reduced therapist time. The study also revealed that the guidance of HCP at the beginning of the monitoring is crucial to patients' satisfaction and experience stemming from the usage of the system as evidenced by the high correlation between the recommendation of the application, and it suitability to improve pain management and to provide medical information. There were no significant differences regarding to improvements in the quality of pain treatment between intervention group and control group. Based on the data collected during the RCT a clinical decision support system (CDSS) was developed so as to offer capabilities of tailored alarms, reports, and clinical guidance. This CDSS, called Patient Oriented Method of Pain Evaluation System (POMPES), is based on the combination of several statistical models (one-way ANOVA, Kruskal-Wallis and Tukey-Kramer) with an imputation model based on linear regression. This system resulted in fully accuracy related to decisions suggested by the system compared with the medical diagnosis, and therefore, revealed it suitability to manage the pain. At last, based on the aerospace systems capability to deal with different complex data sources with varied complexities and accuracies, an innovative model was proposed. This model is characterized by a qualitative analysis stemming from the data fusion method combined with a quantitative model based on the comparison of the standard deviation together with the values of mathematical expectations. This model aimed to compare the effects of technological and pen-and-paper systems when applied to different dimension of pain, such as: pain intensity, anxiety, catastrophizing, depression, disability and interference. It was observed that pen-and-paper and technology produced equivalent effects in anxiety, depression, interference and pain intensity. On the contrary, technology evidenced favourable effects in terms of catastrophizing and disability. The proposed method revealed to be suitable, intelligible, easy to implement and low time and resources consuming. Further work is needed to evaluate the proposed system to follow up participants for longer periods of time which includes a complementary RCT encompassing patients with chronic pain symptoms. Finally, additional studies should be addressed to determine the economic effects not only to patients but also to the healthcare system

Study protocol for a pragmatic randomised controlled trial in general practice investigating the effectiveness of acupuncture against migraine

<p>Abstract</p> <p>Background</p> <p>Migraine is a chronic neurologic disease that can severely affect the patient's quality of life. Although in recent years many randomised studies have been carried out to investigate the effectiveness of acupuncture as a treatment for migraine, it remains a controversial issue. Our aim is to determine whether acupuncture, applied under real conditions of clinical practice in the area of primary healthcare, is more effective than conventional treatment.</p> <p>Methods/Design</p> <p>The design consists of a pragmatic multi-centre, three-armed randomised controlled trial, complemented with an economic evaluation of the results achieved, comparing the effectiveness of verum acupuncture with sham acupuncture, and with a control group receiving normal care only.</p> <p>Patients eligible for inclusion will be those presenting in general practice with migraine and for whom their General Practitioner (GP) is considering referral for acupuncture. Sampling will be by consecutive selection, and by randomised allocation to the three branches of the study, in a centralised way following a 1:1:1 distribution (verum acupuncture; sham acupuncture; conventional treatment). Secondly, one patient in three will be randomly selected from each of the acupuncture (verum or sham) groups for a brain perfusion study (by single photon emission tomography). The treatment with verum acupuncture will consist of 8 treatment sessions, once a week, at points selected individually by the acupuncturist. The sham acupuncture group will receive 8 sessions, one per week, with treatment being applied at non-acupuncture points in the dorsal and lumbar regions, using the minimal puncture technique. The control group will be given conventional treatment, as will the other two groups.</p> <p>Discussion</p> <p>This trial will contribute to available evidence on acupuncture for the treatment of migraine. The primary endpoint is the difference in the number of days with migraine among the three groups, between the baseline period (the 4 weeks prior to the start of treatment) and the period from weeks 9 to 12. As a secondary aspect, we shall record the index of laterality and the percentage of change in the mean count per pixel in each region of interest measured by the brain perfusion tomography, performed on a subsample of the patients within the real and sham acupuncture groups.</p> <p>Trial registration</p> <p>Current Controlled Trials ISRCTN98703707.</p

Effects of oculomotor rehabilitation in children with visual and/or oculomotor dysfunction: a systematic review

A visão é essencial para o desenvolvimento das crianças, facilitando as suas habilidades cognitivas, sociais e motoras, e é importante, em especial, para o seu sucesso escolar. A presente revisão sistemática teve como objetivo estudar os efeitos da reabilitação oculomotora nas funções da visão e dos anexos do olho, e nas sensações associadas aos mesmos. Como objetivo secundário, foram estudados os efeitos da reabilitação oculomotora nas funções mentais de crianças com disfunções oculares. A pesquisa foi realizada nas bases de dados PubMed, Web of Science, Psychology and Behavioral Sciences Collection, Academic Search Complete e Scholar Google. Todos os estudos incluídos foram ensaios clínicos randomizados, cuja qualidade metodológica foi avaliada através da Physiotherapy Evidenced Database (PEDro) Scale. Dos nove estudos incluídos na síntese qualitativa, as amostras diziam respeito a crianças com insuficiência de convergência, ambliopia, Transtorno do Défice de Atenção e Hiperatividade, disfunção oculomotora, baixa habilidade de leitura e/ou hipermetropia. Todos os estudos demonstraram associação positiva entre o programa de reabilitação oculomotora em teste e a melhoria dos parâmetros visuais, oculomotores e/ou mentais, em crianças entre os 5 e os 17 anos de idade. Apesar do número de ameaças que colocam em causa as inferências destes achados, os resultados clínicos gerais sugerem que os programas de reabilitação oculomotora têm efeitos positivos nas funções da visão e dos anexos do olho e sensações associadas, bem como na cognição, comportamento e habilidades de leitura de crianças com disfunção oculomotora. São necessárias investigações adicionais para confirmar a eficácia da terapia oculomotora e para escolher o melhor programa de intervenção para cada paciente, dependendo dos objetivos de intervenção e das suas características clínicas e pessoais.Vision is essential to children development, facilitating cognitive, social and motor skills, and it is important, in particular, for school success. This systematic review aimed to study the effects of oculomotor rehabilitation on the functions of vision and structures adjoining the eye and on sensations associated, in children. As a secondary objective, the effects of oculomotor rehabilitation on the mental functions of children with ocular dysfunctions was studied. The research was conducted in PubMed, Web of Science, Psychology and Behavioral Sciences Collection, Academic Search Complete and Scholar Google databases. All the studies included were randomized controlled trials (RCT), which methodological quality was assessed with The Physiotherapy Evidence Database (PEDro) Scale. From the nine studies included in qualitative synthesis, the samples concerned children with convergence insufficiency, amblyopia, Attention Deficit Hyperactivity Disorder (ADHD), oculomotor dysfunction, poor reading skills, and/or hypermetropia. All of the studies demonstrated a positive association between the oculomotor rehabilitation program under test and improvement on visual, oculomotor and/or mental parameters, in children aged between 5 and 17 years old. Despite the number of threats that challenge the inferences of these findings, the overall clinical results suggest that oculomotor rehabilitation programs have positive effects on the functions of vision and structures adjoining the eye and sensations associated, as well as on cognition, behavior and reading skills of children with oculomotor dysfunction. Additional investigation is required to confirm the efficiency of oculomotor therapy and to choose the best intervention program to each patient, depending on the intervention objectives and their clinical and personal characteristics

Sensor Technologies to Manage the Physiological Traits of Chronic Pain: A Review

Non-oncologic chronic pain is a common high-morbidity impairment worldwide and acknowledged as a condition with significant incidence on quality of life. Pain intensity is largely perceived as a subjective experience, what makes challenging its objective measurement. However, the physiological traces of pain make possible its correlation with vital signs, such as heart rate variability, skin conductance, electromyogram, etc., or health performance metrics derived from daily activity monitoring or facial expressions, which can be acquired with diverse sensor technologies and multisensory approaches. As the assessment and management of pain are essential issues for a wide range of clinical disorders and treatments, this paper reviews different sensor-based approaches applied to the objective evaluation of non-oncological chronic pain. The space of available technologies and resources aimed at pain assessment represent a diversified set of alternatives that can be exploited to address the multidimensional nature of pain.Ministerio de Economía y Competitividad (Instituto de Salud Carlos III) PI15/00306Junta de Andalucía PIN-0394-2017Unión Europea "FRAIL

A PRELIMINARY INVESTIGATION OF A VALUES INTERVENTION AND A VALUES REMINDER ON CLINICALLY RELEVANT OUTCOMES

Acceptance and Commitment Therapy (ACT) is designed to target psychological flexibility, broadly defined as engagement with personal values regardless of the presence of difficult private events. As engagement with valued behaviors is imperative to psychological flexibility, clarification of values is an essential skill for clients to learn. Practicing of skills in treatment has historically been a difficult hurdle for clinicians to implement between sessions for clients as well. The present study examined the utility of a novel values card sort activity, as well as the utility of a rubber band to act as a reminding agent for engagement with values. 112 undergraduate students were randomly assigned to one of three conditions: a values card sort condition, a values card sort condition with a rubber band given to the participant, and a control card sort condition. Each participant completed questionnaires assessing connection with values, lack of contact with values, negative affect, and quality of life at baseline and at a one-week follow-up. A series of ANCOVAs were conducted to determine if there were any group differences between the three conditions at follow-up, with baseline scores as a covariate. The analyses indicate no significant difference between the conditions at follow-up across any of the variables of interest. Endorsement of prior therapy experience suggested unique trends and differential reaction to the card sorting activity. These findings suggest the values card sort may not be an effective intervention for subclinical populations but may be a fruitful intervention for clinically-elevated individuals

Fear of movement : epidemiological and clinical evaluation in the Finnish general population and chronic musculoskeletal pain patients and relevance for rehabilitation

Psychological factors are implicated in the transition from acute to chronic back pain as well as in predicting return to work in low back pain patients. Research shows that pain-related fear can be more disabling than pain itself. Earlier studies have demonstrated that fear of movement and fear of (re)injury are better predictors of functional limitations than biomedical parameters. During clinical assessment chronic pain patients frequently demonstrate a variety of pain-associated behaviours. These behaviours may also influence development of chronic pain and disability. The purpose of the research project was; to develop a functional assessment tool for the assessment of pain behaviour and to investigate the relationship between pain behaviour, fear of movement, physical function, and disability, and to study the association between fear of movement and leisure time physical activity (LTPA) among chronic pain patients, and to estimate the measurement properties of the Finnish version of the Tampa Scale of kinesiophobia (TSK-FIN) among chronic pain patients, and to investigate fear of movement among the general population. The functional assessment tool for the assessment of pain behaviour showed good reliability. There was a strong correlation between pain behaviour and subjective pain report and disability and moderate correlation to pain behaviour. The inverse associations between total pain behaviour and physical function tests were strong. The internal consistencies were good and test-retest reliability of the TSK-FIN was excellent for both paper and computer versions. The mean difference between the computer and the paper version was 1.9. However, in terms of individual variability, 62% varied by less than 3 points and 44% by less than 2 points. The level of kinesiophobia was associated with disability and depressive symptoms. Kinesiophobia and leisure time physical activity were inversely associated. For the purpose of the studying the effect of pain management program, the patients were classified into three groups based on distribution of the TSK-FIN. At baseline, the mean LTPA index of the high kinesiophobia group was lower than in the low and medium kinesiophobia groups. At the 6-month follow-up, patients with high kinesiophobia had increased their physical activity to the same level as the other groups. This change was maintained up to the 12-month follow-up. Among general population, men over 55 and women over 65 had higher scores than younger ones. The presence of cardiovascular disease, musculoskeletal disease or mental disorder was significantly associated with a higher TSK-FIN score compared to the absence of the aforementioned disorders. Among general population, 14.2% received the generally used cut-off point 40 points or more for increased kinesiophobia. Conclusion: The results of this research project suggest that both the assessment of pain behaviour and the TSK-FIN demonstrated acceptable reliability. Among patients with musculoskeletal pain, the fear of movement and leisure time physical activity are inversely related. A pain management program seems to have favourable effect on the fear of movement and physical activity. Among general population age and TSK-FIN score are associated. Among general population, 14 % scored over cut-off point 40 points or more.Psykologiset tekijät ovat mukana kivun kroonistumisessa ja ennustavat työhön palaamista alaselkäpotilailla. Tutkimuksen osoittavat että kipuun liittyvä pelko voi aiheuttaa enemmän toimintakyvyn haittaa kuin kipu itsessään ja että, liikkumisen pelko ja uudelleen loukkaantumisen pelko ennustavat paremmin toiminnan rajoituksia kuin biolääketieteelliset tekijät. Kliinisen tutkimuksen aikana kroonisilla kipupotilailla on usein erilaisia kipuun liittyviä toimintatapoja, jotka voivat osaltaan vaikuttaa kivun kroonistumiseen ja toimintakyvyn haitan kehittymiseen. Tutkimuksen tarkoituksena oli; kehittää toiminnallinen arviointimenetelmä kipukäyttäytymisen arviointiin sekä tutkia kipukäyttäytymisen, liikkumisen pelon, fyysisen toimintakyvyn ja toimintakyvyn haitan välisiä yhteyksiä, ja tutkia liikkumisen pelon ja vapaa-ajan liikunta-aktiivisuuden (LTPA) yhteyttä kroonisilla kipupotilailla, ja arvioida suomenkielisen liikkumisen pelkoa mittaavan Tampa Scale of kinesiophobia (TSK-FIN) mittarin ominaisuuksia kroonisilla kipupotilailla, sekä tutkia liikkumisen pelkoa normaaliväestössä. Tutkimuksessa kehitetty kipukäyttäytymisen arviointimenetelmän osoittautui hyvin toistettavaksi. Kipukäyttäytymisellä oli vahva yhteys koettuun kipuun ja toimintakyvyn haittaan ja kohtalainen yhteys liikkumisen pelkoon. Korostuneella kipukäyttäytymisellä oli vahva käänteinen yhteys suoriutumiseen fyysisen toimintakyvyn testeistä. TSK-FIN mittarin paperilla sekä tietokoneella täytettävät versiot osoittautuivat sisäisesti johdonmukaisiksi sekä hyvin toistettavaksi. Keskiarvo tietokoneella täytettynä oli 1.9 pistettä korkeampi kuin paperiversiossa. Kuitenkin yksilöllisestä vaihtelusta 62 % oli vähemmän kuin kolme pistettä ja 44 % vähemmän kuin kaksi pistettä. Liikkumisen pelko oli yhteydessä koettuun toimintakyvyn haittaan ja masennusoireisiin ja käänteisesti yhteydessä vapaa-ajan liikunta-aktiivisuuteen. Kuntoutuksen vaikutuksen arviointia varten potilaat jaettiin kolmeen ryhmään liikkumisen pelon suhteen. Kuntoutuksen alkutilanteessa keskimääräinen LTPA -indeksi oli matalampi korkean liikkumisen pelon -ryhmässä kuin matalan ja keskitason liikkumisen pelon -ryhmissä. Kuuden kuukauden seurannassa korkean liikkumisen pelon ryhmään kuuluvien liikunta-aktiivisuus lisääntyi samalle tasolle kuin muilla ryhmillä. Muutos säilyi 12 kuukauden seurannassa. Normaaliväestössä yli 55 vuotiailla miehillä ja yli 65 vuotiailla naisilla oli korkeampi TSK-FIN pistemäärä kuin nuoremmilla. Sydän- ja verisuonitaudit, TULE-vaivat tai mielenterveyden häiriöt olivat yhteydessä suurentuneeseen TSK-FIN pistemäärään. Normaaliväestössä 14.2 % ylitti korostunutta liikkumisen pelkoa indikoivan TSK-FIN pistemäärän 40 pistettä tai enemmän. Yhteenveto: Tutkimustulosten perusteella kipukäyttäytymisen arviointimenetelmä ja TSK-FIN mittari ovat luotettavia. Tule potilailla liikkumisen pelko ja vapaa-ajan liikunta-aktiivisuus ovat käänteisesti yhteydessä. Moniammatillisella kipukuntoutuksella on tämän tutkimuksen mukaan edullinen vaikutus liikkumisen pelon vähenemiseen ja vapaa-ajan liikunta-aktiivisuuden lisäämiseen, jolloin pelon ja liikkumattomuuden negatiivinen noidankehä saadaan katkaistua. Normaaliväestössä ikä ja liikkumisen pelko ovat yhteydessä toisiinsa. Normaaliväestöstä n. 14 % ylittää TSK-FIN mittarin raja-arvon 40 pistettä

Outcomes of Rotator Cuff Surgery in Utah Workers’ Compensation Patients

Currently, rotator cuff injuries are the most common problem for the shoulder and accounted for 4.1 million physicians visits. Partial and full thickness tears are more common in people over the age of 50. The increased prevalence of rotator cuff injuries in the United States population certainly affects the working population and often represents a significant economic burden for employers. Few studies have examined outcomes in worker compensation patients or considered biopsychosocial predictive variables for rotator cuff repairs. The current study aimed to characterize injured workers who have undergone rotator cuff repairs across a number of pre- and postprocedural variables, evaluate multidimensional functional and quality of life outcomes, and examine biopsychosocial variables predictive of success and failure in this sample. The current study examined 93 injured workers who had undergone at least one rotator cuff repair within the past five years. Participants were solicited through the Worker’s Compensation Fund of Utah (WCF) computerized database. The current study used a retrospective cohort design, patients’ medical charts were reviewed, and various preprocedural variables were coded for analysis including age at the time of the rotator cuff repair, lawyer involvement in the claim, prior shoulder surgery history, and quantity of other compensation claims. Of the total sample, 47 patients (50.5%) were contacted and completed outcome surveys that assessed patient satisfaction, shoulder functional impairment, disability status, and general physical and mental health functioning. Findings revealed that approximately one third of the patients were totally disabled (29.8%), had poor shoulder specific functioning (36.2%), and were dissatisfied with their current shoulder condition (31.7%). A multivariate regression model was utilized in predicting patient outcomes. Specifically, the number of WCF claims of the patient was a robust predictor of multidimensional outcomes, while age and gender were less predictive of outcomes, and the presence of a prior shoulder surgery reflected no predictive power. Results of descriptive, correlational, and regression analyses are compared to existing data for rotator cuff repair patients when available or to other surgical procedures with similar populations. The study limitations are discussed, such as small sample size, the retrospective design, and lack of matched controls