Combining a psychological intervention with physiotherapy: A systematic review to determine the effect on physical function and quality of life for adults with chronic pain

© 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group. Background: Chronic pain affects approximately 28 million people in the UK. It does not always respond to conventional curative treatments and can have a devastating impact on an individual’s ability to function and perform life roles in the way they would like. Psychological approaches to pain management have been advocated for over 40 years, but it is unclear whether the addition of such approaches to physiotherapy increases treatment effectiveness. Objectives: To systematically review the literature to determine whether the addition of psychological approaches to physiotherapy is more effective in improving physical functioning and quality of life than physiotherapy alone. Methods: An electronic database search focused on randomised controlled trials comparing a physiotherapy intervention for chronic pain with a matched intervention with an additional psychological therapy component. All eligible studies were independently reviewed by two researchers and the strength of evidence and results evaluated. A meta-analysis was conducted on post-test mean data for physical functioning. Results: Eight studies were identified for inclusion. Meta-analysis of the data showed combined treatments to be superior in modifying functional outcomes (standardised mean difference −1.12 95% confidence intervals −1.94 to −0.31). This was echoed in the narrative review of the quality of life evidence. Study quality was variable and thus the findings should be interpreted with caution. Conclusions: There is evidence that combining physiotherapy and psychological approaches improves physical function in chronic pain in comparison with physiotherapy alone. Further examination of this field is required to inform changes in practice and to develop treatment methods

The senses

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Quantitative versus qualitative notions of validity: investigating the validity of PSYCHLOPS as a patient outcome measure in trials of insomnia and sleep problems

Introduction PSYCHLOPS (‘Psychological Outcome Profiles’)is a novel patient-reported outcome measure developed by Ashworth and colleagues that allows clients to evaluate their progress by measuring severity scores for self-defined problems at the start of, during and after therapy. PSYCHLOPS was administered in a study, ‘Resources for Effective Sleep Treatment (REST)’, designed to assess the feasibility of training primary care clinicians (GPs and nurses) to deliver ‘problem focused therapy’ for insomnia to improve sleep outcomes in adults with insomnia. We aimed in this sub-study to assess both qualitative and quantitative notions of validity of PSYCHLOPS in sleep studies. Methods PSYCHLOPS was administered by a practice nurse to trial participants in two intervention primary care sites (participants offered ‘problem focused therapy’) and two control sites (participants offered sleep hygiene information) as part of a cluster randomized feasibility study. Other predetermined outcome measures including the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Beck Depression Inventory (BDI) and sleep diaries. We investigated qualitative and quantitative markers of validity including content validity (nature of response to items), internal validity (reliability), criterion validity (strength of relationship with a related variable) and construct validity (strength of relationship with an underlying variable). Results A qualitative analysis of test content showed a representative sample of the behavior domain expected in relation to sleep problems including sleep, sleep-related problems and underlying psychosocial and physical problems such as anxiety, worry and arthritis. A positive, statistically significant correlation was found between PSYCHLOPS and ISI (Kendall’s tau = 0.47, p<0.001) but not between PSYCHLOPS and PSQI (Kendall’s tau = 0.13, p=0.24) suggesting partial criterion validity with regards to insomnia impact. We also found a positive correlation between PSYCHLOPS and BDI and (Kendall’s tau = 0.47, p<0.001) indicating construct validity. Conclusion PSYCHLOPS demonstrated some aspects of quantitative validity supporting its wider use in this study setting. However, applying qualitative notions of validity uncovered a number of assumptions and response biases that should be acknowledged in future studies using the tool. Qualitative analysis added an additional dimension to the assessment of validity which should be considered in other validation studies

Evaluation of the accuracy of serum MMP-9 as a test for colorectal cancer in a primary care population

Background Bowel cancer is common and is a major cause of death. Meta-analysis of randomised controlled trials estimates that screening for colorectal cancer using faecal occult blood (FOB) test reduces mortality from colorectal cancer by 16%. However, FOB testing has a low positive predictive value, with associated unnecessary cost, risk and anxiety from subsequent investigation, and is unacceptable to a proportion of the target population. Increased levels of an enzyme called matrix metalloproteinase 9 (MMP-9) have been found to be associated with colorectal cancer, and this can be measured from a blood sample. Serum MMP-9 is potentially an accurate, low risk and cost-effective population screening tool. This study aims to evaluate the accuracy of serum MMP-9 as a test for colorectal cancer in a primary care population. Methods/Design People aged 50 to 69 years, who registered in participating general practices in the West Midlands Region, will be asked to complete a questionnaire that asks about symptoms. Respondents who describe any colorectal symptoms (except only abdominal bloating and/or anal symptoms) and are prepared to provide a blood sample for MMP9 estimation and undergo a colonoscopy (current gold standard investigation) will be recruited at GP based clinics by a research nurse. Those unfit for colonoscopy will be excluded. Colonoscopies will be undertaken in dedicated research clinics. The accuracy of MMP-9 will be assessed by comparing the MMP-9 level with the colonoscopy findings, and the combination of factors (e.g. symptoms and MMP-9 level) that best predict a diagnosis of malignancy (invasive disease or polyps) will be determined. Discussion Colorectal cancer is a major cause of morbidity and mortality. Most colorectal cancers arise from adenomas and there is a period for early detection by screening, but available tests have risks, are unacceptable to many, have high false positive rates or are expensive. This study will establish the potential of serum MMP-9 as a screening test for colorectal cancer. If it is confirmed as accurate and acceptable, this serum marker has the potential to assist with reducing the morbidity and mortality from colorectal cancer

Panobinostat enhances olaparib efficacy by modifying expression of homologous recombination repair and immune transcripts in ovarian cancer

Histone deacetylase inhibitors (HDACi) sensitize homologous recombination (HR)-proficient human ovarian cancer cells to PARP inhibitors (PARPi). To investigate mechanisms of anti-tumor effects of combined HDACi/PARPi treatment we performed transcriptome analysis in HR- proficient human ovarian cancer cells and tested drug effects in established immunocompetent mouse ovarian cancer models. Human SKOV-3 cells were treated with vehicle (Con), olaparib (Ola), panobinostat (Pano) or Pano+Ola and RNA-seq analysis performed. DESeq2 identified differentially expressed HR repair and immune transcripts. Luciferised syngeneic mouse ovarian cancer cells (ID8-luc) were treated with the HDACi panobinostat alone or combined with olaparib and effects on cell viability, apoptosis, DNA damage and HR efficiency determined. C57BL/6 mice with intraperitoneally injected ID8-luc cells were treated with panobinostat and/or olaparib followed by assessment of tumor burden, markers of cell proliferation, apoptosis and DNA damage, tumor-infiltrating T cells and macrophages, and other immune cell populations in ascites fluid. There was a significant reduction in expression of 20/37 HR pathway genes by Pano+Ola, with immune and inflammatory-related pathways also significantly enriched by the combination. In ID8 cells, Pano+Ola decreased cell viability, HR repair, and enhanced DNA damage. Pano+Ola also co-operatively reduced tumor burden and proliferation, increased tumor apoptosis and DNA damage, enhanced infiltration of CD8+ T cells into tumors, and decreased expression of M2-like macrophage markers. In conclusion, panobinostat in combination with olaparib targets ovarian tumors through both direct cytotoxic and indirect immune-modulating effects

Prioritising outcomes measures for ambulance service care: a three stage consensus study

Background Historically ambulance care quality and performance has been measured by response times rather than clinical need or effectiveness. This limits the evidence about the effectiveness of the care the ambulance service provides. The Pre-hospital Outcomes for Evidence Based Evaluation (PhOEBE) project is a 5 year research programme which aims to develop new ways of measuring the performance, quality and impact of ambulance service care that better reflect the care provided. Methods We held a 1 day consensus event with a multi-stakeholder group to identify and prioritise which features of ambulance service care are important and worth further development as measures of performance and quality. The day comprised a series of small group discussions to share opinions about measures identified from literature reviews and the opportunity for participants to add their ideas, together with a live vote to help identify and rank measures for further development. Time measures were considered in a separate online questionnaire. The results from the online questionnaire and Consensus Event were fed into a Delphi study. Results 43 participants attended the consensus event, representing a range of participant groups including patient and public, ambulance services, commissioners and policy groups. The top 5 outcome measures prioritised by the participants were: Accuracy of dispatch decisions; Completeness and accuracy of patient records; Accuracy of call taker identification of different conditions or needs (e.g. heart attack, stroke, suitable for nurse advice); Pain measurement and symptom relief; Patient experience. From the online survey of time measures the top 5 measures were Time of call to time of arrival at scene; Time symptoms start (e.g. chest pain) to time of treatment with balloon for heart attack; Time taken to answer the emergency call; Total time spent on scene; Incident or start of symptoms to calling the ambulance service Conclusions Using consensus methods we have identified a set of outcome measures that can potentially be used to measure the performance and quality of ambulance service care. Some of these measures fit with existing government targets, such as response times and time taken to answer the emergency call. However most measures are new ways of measuring ambulance service care and the importance of these measures and methods of measurement will be assessed as part of an on-going Delphi study

Is copyright blind to the visual?

This article argues that, with respect to the copyright protection of works of visual art, the general uneasiness that has always pervaded the relationship between copyright law and concepts of creativity produces three anomalous results. One of these is that copyright lacks much in the way of a central concept of 'visual art' and, to the extent that it embraces any concept of the 'visual', it is rooted in the rhetorical discourse of the Renaissance. This means that copyright is poorly equipped to deal with modern developments in the visual arts. Secondly, the pervasive effect of rhetorical discourse appears to have made it particularly difficult for copyright law to strike a meaningful balance between protecting creativity and permitting its use in further creative works. Thirdly, just when rhetorical discourse might have been useful in identifying the significance and materiality of the unique one-off work of visual art, copyright law chooses to ignore its implications

Is the pharmacy profession innovative enough?: meeting the needs of Australian residents with chronic conditions and their carers using the nominal group technique

Background Community pharmacies are ideally located as a source of support for people with chronic conditions. Yet, we have limited insight into what innovative pharmacy services would support this consumer group to manage their condition/s. The aim of this study was to identify what innovations people with chronic conditions and their carers want from their ideal community pharmacy, and compare with what pharmacists and pharmacy support staff think consumers want. Methods We elicited ideas using the nominal group technique. Participants included people with chronic conditions, unpaid carers, pharmacists and pharmacy support staff, in four regions of Australia. Themes were identified via thematic analysis using the constant comparison method. Results Fifteen consumer/carer, four pharmacist and two pharmacy support staff groups were conducted. Two overarching themes were identified: extended scope of practice for the pharmacist and new or improved pharmacy services. The most innovative role for Australian pharmacists was medication continuance, within a limited time-frame. Consumers and carers wanted improved access to pharmacists, but this did not necessarily align with a faster or automated dispensing service. Other ideas included streamlined access to prescriptions via medication reminders, electronic prescriptions and a chronic illness card. Conclusions This study provides further support for extending the pharmacist’s role in medication continuance, particularly as it represents the consumer’s voice. How this is done, or the methods used, needs to optimise patient safety. A range of innovative strategies were proposed and Australian community pharmacies should advocate for and implement innovative approaches to improve access and ensure continuity of care

Disease Status and Pubertal Stage Predict Improved Growth in Anti-TNF Therapy for Pediatric Inflammatory Bowel Disease

Background: Growth failure is well-recognised in pediatric Inflammatory Bowel Disease (PIBD; &lt;18 years). We aimed to examine whether anti-Tumor Necrosis Factor (TNF) therapy improves growth in a PIBD population-based cohort. Methods: A retrospective review of all Scottish children receiving anti-TNF (infliximab (IFX) and adalimumab (ADA)) from 2000-2012 was performed; height was collected at: 12 months before anti-TNF (T-12), start (T0) and 12 (T+12) months after anti-TNF. Results: 93/201 treated with IFX and 28/49 for ADA had satisfactory growth data; 66 had full pubertal data. Univariate analysis demonstrated early pubertal stages (Tanner 1-3 n = 44 vs. T4-5 n = 22), disease remission, disease duration &gt;=2 years and duration of IFX &gt;=12 months were associated with improved linear growth for IFX; for ADA only improvement was seen in Tanner 1-3. For IFX, Tanner 1-3 median [DELTA] ht SDS -0.3 (-0.7,0.2) at T0 changed to 0.04 (-0.5, 0.7) at T+12 (p &lt; 0.001) vs -0.01 (-0.5, 0.9) at T0 in T4-5 changed to -0.01 (-0.4, 0.2) at T+12 (p &gt; 0.05). For IFX disease duration &gt;=2 year, median [DELTA] ht SDS was -0.13 (-0.6, 0.3) at T0 then 0.07 (-0.3, 0.6) at T+12 (p &lt; 0.001). Remission improved [DELTA] ht SDS (median [DELTA] ht SDS -0.14 (-0.6, 0.3) at T0 to 0.17 (-0.2, 0.7) at T+12 (p &gt; 0.001)). Multiple regression analysis demonstrated corticosteroid usage at T0 predicted improved [DELTA] ht SDS at T+12 for IFX and ADA. Conclusions: Anti-TNF therapy is more likely to be associated with growth improvement when used at earlier stages of puberty with remission a key growth-promoting strategy in Paediatric Crohn's disease