Cognitive-behavioural treatment for subacute and chronic neck pain

BACKGROUND: Although research on non-surgical treatments for neck pain (NP) is progressing, there remains uncertainty about the efficacy of cognitive-behavioural therapy (CBT) for this population. Addressing cognitive and behavioural factors might reduce the clinical burden and the costs of NP in society.OBJECTIVES: To assess the effects of CBT among individuals with subacute and chronic NP. Specifically, the following comparisons were investigated: (1) cognitive-behavioural therapy versus placebo, no treatment, or waiting list controls; (2) cognitive-behavioural therapy versus other types of interventions; (3) cognitive-behavioural therapy in addition to another intervention (e.g. physiotherapy) versus the other intervention alone.SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, and PubMed, as well as ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to November 2014. Reference lists and citations of identified trials and relevant systematic reviews were screened.SELECTION CRITERIA: We included randomised controlled trials that assessed the use of CBT in adults with subacute and chronic NP.DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach.MAIN RESULTS: We included 10 randomised trials (836 participants) in this review. Four trials (40%) had low risk of bias, the remaining 60% of trials had a high risk of bias.The quality of the evidence for the effects of CBT on patients with chronic NP was from very low to moderate. There was low quality evidence that CBT was better than no treatment for improving pain (standard mean difference (SMD) -0.58, 95% confidence interval (CI) -1.01 to -0.16), disability (SMD -0.61, 95% CI -1.21 to -0.01), and quality of life (SMD -0.93, 95% CI -1.54 to -0.31) at short-term follow-up, while there was from very low to low quality evidence of no effect on various psychological indicators at short-term follow-up. Both at short- and intermediate-term follow-up, CBT did not affect pain (SMD -0.06, 95% CI -0.33 to 0.21, low quality, at short-term follow-up; MD -0.89, 95% CI -2.73 to 0.94, low quality, at intermediate-term follow-up) or disability (SMD -0.10, 95% CI -0.40 to 0.20, moderate quality, at short-term follow-up; SMD -0.24, 95% CI-0.54 to 0.07, moderate quality, at intermediate-term follow-up) compared to other types of interventions. There was moderate quality evidence that CBT was better than other interventions for improving kinesiophobia at intermediate-term follow-up (SMD -0.39, 95% CI -0.69 to -0.08, I(2) = 0%). Finally, there was very low quality evidence that CBT in addition to another intervention did not differ from the other intervention alone in terms of effect on pain (SMD -0.36, 95% CI -0.73 to 0.02) and disability (SMD -0.10, 95% CI -0.56 to 0.36) at short-term follow-up.For patients with subacute NP, there was low quality evidence that CBT was better than other interventions at reducing pain at short-term follow-up (SMD -0.24, 95% CI -0.48 to 0.00), while no difference was found in terms of effect on disability (SMD -0.12, 95% CI -0.36 to 0.12) and kinesiophobia.None of the included studies reported on adverse effects.AUTHORS' CONCLUSIONS: With regard to chronic neck pain, CBT was found to be statistically significantly more effective for short-term pain reduction only when compared to no treatment, but these effects could not be considered clinically meaningful. When comparing both CBT to other types of interventions and CBT in addition to another intervention to the other intervention alone, no differences were found. For patients with subacute NP, CBT was significantly better than other types of interventions at reducing pain at short-term follow-up, while no difference was found for disability and kinesiophobia. Further research is recommended to investigate the long-term benefits and risks of CBT including for the different subgroups of subjects with N

The Use of Pattern Differentiation in WHO-Registered Traditional Chinese Medicine Trials – a systematic review

Introduction: Pattern differentiation is a critical component for traditional Chinese medicine (TCM) diagnosis and treatment. However, the issue of whether pattern differentiation is appropriately applied in TCM Interventional trials, including Chinese herbal medicine (CHM) interventions and non-herbal TCM interventions, is unclear. The aim of this study was to i) systematically review the current status of pattern differentiation used in WHO-registered clinical trials for different types of TCM interventions; and ii) provide suggestions for improving the use of pattern differentiation in future clinical trial design. Methods: The World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) database was searched for all TCM interventional trials registered up to 31 December 2017. In this systematic review trials with a TCM pattern differentiation in their design were included. Descriptive statistics were collated to demonstrate the characteristics of pattern differentiation applied for different TCM interventional trials. Results: Among 2,955 TCM interventional trials registered during 1999-2017, 376 (12.7%) trials included pattern differentiation. Of 376 trials, the use of pattern differentiation was identified in –title (30.6%), objective (50.5%), participants inclusion 4 (100%), outcomes (43.6%) and study background (12.5%). Further, 85.4% reported the specific name of the TCM intervention, 10.6% provided the intervention’s targeted pattern, 83.8% reported the specific name of the TCM pattern, 7.2% presented diagnostic criteria for the pattern studied, and 19.1% adopted a pattern-related outcome as primary outcome for evaluation. Conclusion: The reporting and application of pattern differentiation in TCM trials were inadequate and confusing, which was mainly due to lack of clarity regarding study design, objectives, diagnostic criteria and outcomes

Acupuncture in Modern Medicine

This book contains four integrated sections: 1) Acupuncture Research; 2) New Developments in Acupuncture; 3) Acupuncture Therapy for Clinical Conditions and 4) Assessment and Accessibility in Acupuncture Therapy. Section 1 provides updates on acupuncture research. From acupuncture effects in modulation of immune system to the role of nitric oxide in acupuncture mechanisms, chapters in this section offer readers the newest trends in acupuncture research. Section 2 summarizes new developments in acupuncture. The included chapters discuss new tools and methods in acupuncture such as laser acupuncture, sham needles, and new technologies. Section 3 discusses acupuncture therapy for clinical conditions. The chapters in this section provide comprehensive and critical views of acupuncture therapy and its application in common clinical practice. Section 4 takes a new look at the issues related to assessment and accessibility in acupuncture therapy. These issues are central to developing new standards for outcome assessment and policies that will increase the accessibility to acupuncture therapy

Biopsychosocial evaluation of a spinal triage service delivered by physiotherapists in collaboration with orthopaedic surgeons

Background: Low back pain (LBP) and low back related disorders are highly prevalent and associated with a considerable burden of pain, disability and work loss. People with a variety of low back-related complaints comprise a large proportion of referrals made to orthopedic surgeons and many of these patients are not considered to be surgical candidates or have not maximized their non-surgical options for managing their low back-related complaints. Objectives: We sought to evaluate the impact of a triage assessment program delivered by physiotherapists using a variety of approaches. Informed by a biopsychosocial model, the objectives of this dissertation were: 1) To determine the short term impact of a physiotherapy triage assessment for people with low back-related disorders on participant self-reported pain, function and quality of life and patient and referring practitioner satisfaction. 2) To determine which demographic, clinical, psychosocial and environmental factors are predictive of improved self-reported pain, function, quality of life and participant and referring practitioner satisfaction. 3) To determine the diagnostic and treatment recommendation concordance between physiotherapists and orthopaedic surgeons, using a newly developed clinical classification tool, for people presenting to a spinal triage assessment service with low back complaints. Methods: Two approaches were used to achieve the aforementioned objectives: a prospective observational study (n=115) to address the first two objectives and a sub-group reliability study (n=45) to address the third objective. Results: There was a mean overall significant improvement in the SF-36 Physical Component Summary at the 4-6 week post-test time point and relatively high satisfaction reported by participants and referring care providers. Qualitative analysis of comments revealed a variety of positive, negative and other contextual factors that may impact outcomes. A variety of different sociodemographic, psychological, clinical and other variables were associated with success or improvement in each respective outcome. There may be a potential mechanism of reassurance that occurs during the spinal triage assessment process as those with higher psychological distress were more likely to improve on certain outcomes. There was high diagnostic concordance between physiotherapists and an orthopaedic surgeon; however, there were more differences in management recommendations between the surgeon and a solo physiotherapist versus physiotherapists working in a collaborative team. Conclusions: A spinal triage assessment program delivered by physiotherapists has the potential to positively impact a variety of patient-related short term outcomes including satisfaction. Further study is needed to examine longer-term outcomes and which biopsychosocial factors may impact these outcomes

The role of cervical spine range of motion in recovery from whiplash associated disorders

This thesis investigates the role of cervical spine Range of Motion in the recovery from Whiplash Associated Disorders. In clinical practice, Health Care Professionals attach value to measurements of cervical spine Range of Motion for diagnostic, prognostic and treatment evaluation purposes. A systematic literature review found conflicting evidence as to whether cervical spine Range of Motion was a prognostic factor following a whiplash injury. Greater understanding of prognostic factors such as this may facilitate improvements in patient management. A second systematic literature review investigated the reliability and validity of methods for measuring cervical spine Range of Motion. The Cervical Range Of Motion (CROM) device was found to be the most rigorously tested and clinimetrically promising method and was subsequently investigated for intra- and inter-observer reliability in a group of whiplashinjured individuals and found to be substantially reliable. The CROM device was utilised in a longitudinal cohort study of 599 whiplash-injured patients to investigate the prognostic value of cervical spine Range of Motion for neck painrelated disability and patient-reported recovery at short, medium and long-term follow-up. A patient-reported version of cervical spine Range of Motion was also evaluated as a prognostic factor. Although useful for explaining disability at the time of measurement, active, passive and patient-reported forms of cervical spine Range of Motion were not significant prognostic factors for poor outcome when other physical and psychosocial factors were accounted for. The clinical implication of this research is that if patients are experiencing reduced cervical spine Range of Motion a few weeks after their whiplash injury they will not necessarily have a poor outcome in the longer term as is commonly believed at present

An exploration of the social factors that may have contributed in the UK to perceptions of work-relevant upper limb disorders in keyboard users

The outputs that form the basis of this PhD submission include a web site that summarises a unique collection of over 200 Court Judgments in personal injury claims for work-related upper limb disorders heard in the UK, together with a number of more conventional publications. Individually, these outputs all address upper limb disorders associated with work although they each had slightly different objectives and the audiences for which they were produced significantly influenced the type of publication in which they appeared. Together, they help illustrate when, how and, to some extent, why upper limb disorders associated with keyboard use became the issue it did in the UK in the late 1980s and 1990s. While many might now regard keyboard or computer use as an innocuous task, in the late 1980s and 1990s upper limb disorders associated with keyboard use, particularly computer use, became the subject of litigation, legislation, industrial disputes and widespread publicity. The outputs on which this submission is based, together, suggest that following the importation of the concept of repetitive strain injuries (RSI) from Australia in the later 1980s, the activities of trades unions and journalists in the UK promoted work-relevant upper limb symptoms and disorders associated with keyboard use as work-induced injuries. Subsequently, a small number of successful, union-backed, personal injury claims, which involved contentious medical evidence and perhaps an element of iatrogenesis, were widely promoted as proof that computer use causes injury. Around the same time, the government chose to implement flawed Regulations relating to the design and use of computer workstations, which failed to distinguish between that which might give rise to discomfort, fatigue and frustration and that which might give rise to injury. The existence of these Regulations, which among other things require regular, individual risk assessments of computer users, unlike any other type of work, could be interpreted as further 'proof' that computer use causes injury. The approach to the prevention and management of musculoskeletal disorders advocated in current HSE guidance, including the risk assessment strategy, remain capable of generating distorted perceptions of the risks arising from keyboard and computer use

The role of cervical spine range of motion in recovery from whiplash associated disorders

This thesis investigates the role of cervical spine Range of Motion in the recovery from Whiplash Associated Disorders. In clinical practice, Health Care Professionals attach value to measurements of cervical spine Range of Motion for diagnostic, prognostic and treatment evaluation purposes. A systematic literature review found conflicting evidence as to whether cervical spine Range of Motion was a prognostic factor following a whiplash injury. Greater understanding of prognostic factors such as this may facilitate improvements in patient management. A second systematic literature review investigated the reliability and validity of methods for measuring cervical spine Range of Motion. The Cervical Range Of Motion (CROM) device was found to be the most rigorously tested and clinimetrically promising method and was subsequently investigated for intra- and inter-observer reliability in a group of whiplashinjured individuals and found to be substantially reliable. The CROM device was utilised in a longitudinal cohort study of 599 whiplash-injured patients to investigate the prognostic value of cervical spine Range of Motion for neck painrelated disability and patient-reported recovery at short, medium and long-term follow-up. A patient-reported version of cervical spine Range of Motion was also evaluated as a prognostic factor. Although useful for explaining disability at the time of measurement, active, passive and patient-reported forms of cervical spine Range of Motion were not significant prognostic factors for poor outcome when other physical and psychosocial factors were accounted for. The clinical implication of this research is that if patients are experiencing reduced cervical spine Range of Motion a few weeks after their whiplash injury they will not necessarily have a poor outcome in the longer term as is commonly believed at present.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Tinnitus, biomarkers and quality of life in an older population

Tinnitus is a symptom involving the perception of sound in the ears or head, without a corresponding external acoustic stimulus. It is related to many different conditions and has a major impact on quality of life of the affected person. Currently, its diagnosis and monitoring are based on subjective audiometric and psychometric measures. There are no objective methods for tinnitus identification. In addition, the pathophysiological mechanisms underlying tinnitus remains unknown. The purpose of this thesis was to study the mechanisms underlying tinnitus and their relationship to hearing loss, being that hearing loss is the comorbidity most frequently associated with tinnitus. It also aimed to evaluate the contribution of genetic, audiological and immunological factors to the etiology of tinnitus. For this purpose, systematic reviews (SR) were performed, in order to account the state of art, the perspectives of the patient and their relatives, and previous clinical trials of tinnitus treatments. SRs contributed to the identification of a pool of tinnitus-related complaint domains used by COMIT’ID (Core outcome measures in tinnitus international Delphi) in a 3-round internet-based Delphi survey to identifying core outcome sets (COS), i.e., which complaints related to tinnitus are essential for evaluation in clinical trials. These recommendations are specific to the three main therapeutic modalities: sound, psychological, and pharmacological. In order to contribute to the standardization of tinnitus clinical evaluation and treatment, TINNET, a European network for scientific tinnitus research, was created. Among the different activities carried out in were a systematic review of existing national clinical practice guidelines for the diagnosis and treatment of tinnitus. This review contributed to the development of a multidisciplinary European guideline for tinnitus: diagnosis, evaluation and treatment. This guideline was presented at TINNET final meeting and it is being disseminated widely. Another aim of the present thesis was to review work on somatosensory tinnitus (pathophysiology, diagnosis, treatment and the participation in an international Delphi consensus group on the diagnosis of this subtype of tinnitus), to contribute to a better understanding of this subtype of tinnitus. In order to achieve the objectives of this PhD study, 114 participants aged 55 to 75 years were recruited from the Portuguese population. Participants were divided into four groups according to the presence/absence of tinnitus and hearing loss. The completion of the study protocol gave rise to four original research articles, including a demographic characterization, relevant psychological and quality of life aspects comparing the studied population and the published literature, audiologic markers of tinnitus, and immunological profile of population and biomarkers of presbycusis and tinnitus. The results point to hearing loss as a risk factor for the development of tinnitus and psychological complaints as a risk factor for more severe tinnitus and consequently less quality of life in patients with this symptom. In characterizing audiological markers, the presence of previous noise exposure and the hearing loss increased the probability of developing tinnitus. Also, participants with an abrupt onset of tinnitus and who had a negative effect or rebound on residual inhibition were more likely to develop severe or catastrophic tinnitus. For the population with tinnitus, a reduction in amplitude of auditory evoked potentials wave I and a higher values in the 'Ratio of Waves V/I for both ears' were associated with a greater probability of developing severe or catastrophic tinnitus. The inflammatory profile of the study population showed significant differences in IL10 levels between the group with and without tinnitus. IL1α was significantly higher in patients with tonal tinnitus, while IL2 was higher in participants who reported negative or rebound effect on residual inhibition of tinnitus. A negative correlation was also found between IL10 and tinnitus duration, and between HSP70 and tinnitus intensity. Biomarkers were explored in this thesis. A systematic review was performed to synthesize evidence for the existence and clinical usefulness of biomarkers. GRM7 and NAT2 were evaluated in the thesis population. The results indicate a higher prevalence of the T allele in the GRM7 gene (60.3% T/T and 33.3% A/T). Participants with a T/T genotype appeared to be at a higher risk for ARHL development, and 33% have a lower risk of developing tinnitus compared to participants with A/A and A/T genotype. Regarding the NAT2 phenotype, the slow acetylator (53%) was most common, followed by the intermediate acetylator (35.9%). These results suggest that the AT allele of GRM7 and the slow acetylating phenotype of Nat2 are potential biomarkers of tinnitus severity. The results in this thesis are very interesting and original, showing us the need for future research in larger samples, and employing rigorous methodological design in order to control for confounding variables. On the other hand, translational studies may be the key to clarifying the pathophysiologic dilemmas of tinnitus.O acufeno é um sintoma referente à perceção de um som nos ouvidos ou na cabeça, sem que exista um estímulo acústico externo correspondente. Está presente em diferentes patologias (otológicas ou não) e tem um impacto importante na qualidade de vida da pessoa afetada. Atualmente, o seu diagnóstico e monitorização são baseados em medidas subjetivas audiométricas e psicométricas, sendo que não existem métodos objetivos para a identificação do acufeno. Além disso, os mecanismos fisiopatológicos subjacentes ao acufeno subjectivo permanecem desconhecidos. O objetivo da presente tese é estudar os mecanismos subjacentes ao acufeno subjectivo e a sua relação com a surdez, visto que a surdez é a co-morbilidade mais frequentemente associada ao acufeno. Pretende-se também avaliar a contribuição dos fatores genéticos, audiológicos e imunológicos na etiologia do acufeno. Para isso, foram realizadas revisões sistemáticas (RS) sobre esta temática de forma a conhecer o estado de arte, primeiramente em relação à forma como os pacientes e os familiares percecionam o acufeno e também sobre os ensaios clínicos existentes acerca da eficácia do tratamento do acufeno. Ambas as RS contribuíram para a identificação de um conjunto de domínios relacionados com o acufeno, usado pelo COMIT’ID (Core outcome measures in tinnitus international Delphi), num método de consensos Delphi, baseado na Internet, com o objetivo de identificar um ‘Core Outcome Set’ (ou seja definir quais as queixas relacionadas com o acufeno que são imprescindíveis para a sua avaliação) recomendado para ensaios clínicos de eficácia terapêutica para o acufeno assim como para o seu diagnóstico. Estas recomendações são específicas para as três modalidades terapêuticas principais: sonora, psicológica e farmacológica uma vez que cada modalidade tem fundamentos específicos e por isso visam avaliar diferentes aspetos do acufeno. Com o objetivo de contribuir para a padronização da avaliação e do tratamento clínico do acufeno, foi constituída a TINNET, uma rede europeia para a investigação científica do acufeno. Considerando o objetivo do presente estudo e a hipótese de integrar esta rede europeia, foram desenvolvidas um conjunto de atividades que em muito contribuíram para o conhecimento sobre o acufenos. Entre as diferentes atividades realizadas com o apoio da TINNET destaca-se a realização de uma revisão sistemática sobre as ‘guidelines’ clínicas existentes para o diagnóstico e tratamento do acufeno. Esta revisão foi uma das bases que conduziu ao desenvolvimento das ‘guidelines’ europeias multidisciplinares para o acufeno: diagnóstico, avaliação e tratamento. Estas ‘guidelines’ foram apresentadas na conferência final do TINNET e estão atualmente em fase de disseminação. Outro foco de interesse da presente tese foi a realização de trabalhos de revisão sobre o acufeno somatosensorial (nomeadamente sobre a fisiopatologia, diagnóstico e tratamento), bem como a participação num grupo de consenso internacional sobre o diagnóstico deste subtipo do acufeno, de forma a contribuir para uma melhor compreensão deste subtipo do acufeno. Também estas atividades contribuíram para o desenvolvimento de competências cientificas essenciais ao desenvolvimento do presente estudo, dado que permitiram uma melhor compreensão deste subtipo do acufeno, demonstrando-se a heterogeneidade e diversidade do acufeno. De forma a alcançar os objetivos deste estudo de doutoramento, recrutaram-se 114 voluntários da população portuguesa com idade dos 55 aos 75 anos. Os indivíduos desta amostra permitiam a realização de diferentes estudos nomeadamente os laboratoriais, tendo a analise dos resultados envolvido a amostra dividida em quatro grupos consoante a presença/ausência do acufeno e de surdez. Dos resultados desta tese fazem parte quatro artigos originais que e incluem uma caracterização demográfica, aspetos relevantes a nível psicológico e de qualidade de vida, marcadores audiológicos do acufeno, perfil imunológico da população e biomarcadores da presbiacusia e do acufeno. Os resultados obtidos sugerem a perda auditiva como fator de risco para o desenvolvimento do acufeno e as queixas a nível psicológico como fator de risco para o acufeno mais grave e consequentemente associado a menor qualidade de vida nos pacientes com este sintoma. A nível da caracterização dos marcadores audiológicos, verificou-se que a presença de antecedentes de exposição ao ruído e a perda auditiva aumentam a probabilidade de desenvolver acufeno. Também, os participantes com um início abrupto do acufeno e que apresentam um efeito negativo ou ‘rebound’ na inibição residual têm maior probabilidade de desenvolver acufeno grave ou catastrófico. Encontrou-se nos Potenciais Evocados Auditivos, uma redução da amplitude na onda I em pacientes com acufeno, bem como valores maiores no ‘Ratio de amplitude das ondas V e I de ambos ouvidos’ estando associados a maiores probabilidades de desenvolver acufeno severo ou catastrófico. O perfil inflamatório da nossa população mostra diferenças significativas entre o grupo com e sem acufeno quando comparados para a IL10. Quanto à relação entre os parâmetros imunológicos e a acufenometria, verificou-se uma correlação entre o aumento da IL1α e acufeno tonal, bem como entre o aumento da IL2 e a inibição residual do acufeno. Foi também encontrada uma correlação negativa para a IL10 e a duração do acufeno e para o HSP70 e a intensidade do acufeno. Estes resultados são muito originais e suscitam a necessidade de estudos futuros que permitam esclarecer os mecanismos subjacentes às correlações encontradas. Em relação aos biomarcadores, foi efetuada uma revisão sistemática com a finalidade de sintetizar evidências para a existência e utilidade clínica dos biomarcadores para o desenvolvimento ou gravidade do acufeno. Foi também realizado um estudo acerca do papel do GRM7 e do NAT2 na nossa amostra. Os resultados apontam para uma maior prevalência do alelo T no gene GRM7 (60,3% T/T e 33,3% A/T). Os participantes com um genótipo T/T parecem ter um maior risco para o desenvolvimento de ARHL e 33% apresentam menor risco para o desenvolvimento do acufeno, em comparação com indivíduos com A/A e genótipo A/T. Em relação ao fenótipo NAT2, o acetilador lento (53%) foi o mais comum seguido pelo intermediário acetilador (35,9%). Os nossos resultados sugerem que o genótipo A/T de GRM7 e o fenótipo acetilador lento de NAT2 como potenciais biomarcadores da severidade do acufeno. Os resultados obtidos são originais e no seu conjunto são muito interessantes, apontando para a necessidade de estudos futuros em larga escala de forma a aprofundar as conclusões aqui obtidas. Por outro lado, os estudos translacionais poderão ser a chave para esclarecer os dilemas da fisiopatologia do acufeno