Changes in muscle activity and stature recovery after active rehabilitation for chronic low back pain

Patients with low back pain often demonstrate elevated paraspinal muscle activity compared to asymptomatic controls. This hyperactivity has been associated with a delayed rate of stature recovery following spinal loading tasks. The aim of this study was to investigate the changes in muscle activity and stature recovery in patients with chronic low back pain following an active rehabilitation programme. The body height recovery over a 40-min unloading period was assessed via stadiometry and surface electromyograms were recorded from the paraspinal muscles during standing. The measurements were repeated after patients had attended the rehabilitation programme and again at a six-month follow-up. Analysis was based on 17 patients who completed the post-treatment analysis and 12 of these who also participated in the follow-up. By the end of the six months, patients recovered significantly more height during the unloading session than at their initial visit (ES = 1.18; P < 0.01). Greater stature recovery immediately following the programme was associated with decreased pain (r = −0.55; P = 0.01). The increased height gain after six months suggests that delayed rates of recovery are not primarily caused by disc degeneration. Muscle activity did not decrease after treatment, perhaps reflecting a period of adaptation or altered patterns of motor control

"Pacing does help you get your life back": The acceptability of a newly developed activity pacing framework for chronic pain/fatigue.

OBJECTIVES: We have developed and feasibility tested an activity pacing framework for clinicians to standardise their recommendations of activity pacing to patients with chronic pain/fatigue. This study aimed to explore the acceptability and fidelity to this framework in preparation for a future trial of activity pacing. DESIGN: Acceptability and fidelity were explored using semi-structured interviews. Data were analysed using framework analysis. PARTICIPANTS: Patients who attended a rehabilitation programme for chronic pain/fatigue underpinned by the framework, and clinicians (physiotherapists and psychological wellbeing practitioners) who led the programmes. RESULTS: Seventeen interviews were conducted, involving 12 patients with chronic pain/fatigue and five clinicians. The framework analysis revealed four deductive themes: (1) Acceptability of the activity pacing framework, (2) Acceptability of the feasibility study methods, (3) Processes of change and (4) Barriers and facilitators to activity pacing; and one inductive theme: (5) Perspectives of patients and clinicians. CONCLUSIONS: The activity pacing framework appeared acceptable to patients and clinicians, and adherence to the framework was demonstrated. Processes of behaviour change included patients' regulation of activities through activity pacing. Barriers to pacing included work/social commitments and facilitators included identifying the benefits of pacing on symptoms. Different perspectives emerged between clinicians and patients regarding interpretations of symptom-contingent and quota-contingent strategies. The framework recognises fluctuations in symptoms of chronic pain/fatigue and encourages a quota-contingent approach with flexibility. Future work will develop a patient friendly guide ahead of a clinical trial to explore the effects of pacing

The Paediatric Admission Guidance in the Emergency Department (PAGE) supporting documentation

Funded by the National Institute for Health Research (NIHR), the study that led to the production of the Paediatric Admission Guidance in the Emergency Department (PAGE) tool was designed to support better decision-making in paediatric emergency departments about whether children need to be admitted to hospital or can be discharged home safely.The study was conducted over more than 12 months in three dissimilar emergency departments and an urgent care centre. A partnership of the University of Salford, the University of Manchester, and the University of Leicester (and Leicester Hospitals) together with the Northern Care Alliance NHS Group completed the study which has moved into a reporting and dissemination phase including the publication of supporting documentation.A huge sample of 44,501 children and young people participated in this study which has allowed robust analysis of the factors that exert the greatest impact on predicting the need to admit or the safety of discharging children who attend such departments. Moreover, the diversity of the departments in the study indicates that the PAGE instrument (tool) should be effective across the country in a variety of emergency department facilities. PAGE was the highest recruiting research study in England in 2018-2019, and is the highest recruiting paediatric study and third highest recruiting study of any specialty in the history of the whole National Institute for Health Research Clinical Research Network.The supporting documentation includes:1. What is PAGE?2. PAGE - comparison with other scores and systems3. PAGE - cut point consideration

Observational cohort study with internal and external validation of a predictive tool for identification of children in need of hospital admission from the emergency department : the Paediatric Admission Guidance in the Emergency department (PAGE) score

Objectives: To devise an assessment tool to aid discharge and admission decision making in relation to children and young people in hospital urgent and emergency care facilities, and thereby improve the quality of care that patients receive, using a clinical prediction modelling approach Design: Observational cohort study with internal and external validation of a predictive tool Setting: Two general emergency departments and an urgent care centre in the North of England. Participants: The eligibility criteria were children and young people 0-16 years of age who attended one of the three hospital sites within one NHS Trust. Children were excluded if they opted out of the study, were brought to the emergency department (ED) following their death in the community, or arrived in cardiac arrest when the heart rate and respiratory rate would be unmeasurable. Main outcome measures: Admission or discharge. A participant was defined as being admitted to hospital if they left the ED to enter the hospital for further assessment, (including being admitted to an observation and assessment unit or hospital ward), either on first presentation or with the same complaint within seven days. Those who were not admitted were defined as having been discharged. Results: The study collected data on 36365 participants. 15328 participants were included in the final analysis cohort (21045 observations) and 17710 participants were included in the validation cohort (23262 observations). There were 14 variables entered into the regression analysis. Of the 13 that remained in the final model, 10 were present in all 500 bootstraps. The resulting Paediatric Admission Guidance in the Emergency department (PAGE) score demonstrated good internal validity. The C-index (AUROC) was 0.779 (95% CI 0.772 to 0.786). Conclusions: For units without the immediate availability of paediatricians the PAGE score can assist staff to determine risk of admission. Cut off values will need to be adjusted to local circumstance

Inter-rater reliability of paediatric emergency assessment : physiological and clinical features

Objective The Paediatric Admission Guidance in the Emergency Department (PAGE) score is an assessment tool currently in development that helps predict hospital admission using components including patient characteristics, vital signs (heart rate, temperature, respiratory rate, oxygen saturation) and clinical features (e.g. breathing, behaviour, nurse judgement). It aims to assist in safe admission and discharge decision making in environments such as emergency departments and urgent care centres. Determining the inter-rater reliability of scoring tools such as PAGE can be difficult. The aim of this study was to determine the inter-rater reliability of seven clinical components of the PAGE Score. Design Inter-rater reliability was measured by each patient having their clinical components recorded by two separate raters in succession. The first rater was the assessing nurse, the second rater was a research nurse. Setting Two emergency departments and one urgent care centre in the North West of England. Measurements were recorded over one week; data was collected for half a day at each of the three sites. Patients A convenience sample of 90 paediatric attendees (aged 0 to 16), 30 from each of the three sites. Main Outcome Measures Two independent measures for each child were compared using kappa or prevalence-adjusted bias-adjusted kappa (PABAK). Bland-Altman plots were also constructed for continuous measurements. Results Inter-rater reliability ranged from moderate (0.62 [95% CI 0.48 to 0.74] weighted kappa) to very good (0.98 [95% CI 95 to 0.99] weighted kappa) for all measurements except ‘nurse judgement’ for which agreement was fair (0.30 95% CI [0.09 to 0.50] PABAK). Complete information from both raters on all the clinical components of the PAGE score were available for 73 children (81%). These total scores showed good’ inter-rater reliability (0.64 [95% CI 0.53 to 0.74] weighted kappa). Conclusions Our findings suggest different nurses would demonstrate good inter-rater reliability when collecting acute assessments needed for the PAGE score, reinforcing the applicability of the tool. The importance of determining reliability in scoring systems is highlighted and a suitable methodology presented

Patient-reported improvements in health are maintained 2 years after completing a short course of cognitive behaviour therapy, exercise or both treatments for chronic widespread pain: long-term results from the MUSICIAN randomised controlled trial

Objectives The MUSICIAN study has previously shown short-term benefit but only marginal cost-effectiveness for two non-pharmacological interventions for chronic widespread pain (CWP). We wished to determine their long-term effectiveness and cost-effectiveness. Methods A 2×2 factorial randomised controlled trial based in primary care in the UK. People were eligible if they were aged ≥25 years with CWP for which they had consulted their general practitioner. The interventions were a 6-month telephone cognitive behaviour therapy (tCBT) and/or a tailored exercise programme, in comparison to usual care. The primary outcome was patient-reported change in health. Results 884 persons were eligible, 442 were randomised and 81.7% were followed up 24 months post-treatment. In comparison to usual care (positive outcome 12.8%), tCBT (35.4%; OR 3.7 95% CI (1.8 to 8.0)), exercise (29.3%; OR 2.8 95% CI (1.3 to 6.0)) and both interventions (31.2%; OR 3.1 95% CI (1.3 to 6.0)) were significantly more effective. There was only a small decrease in effectiveness over time for individual and combined treatments. Those with more intense/disabling pain, higher distress and those who exhibited passive coping at baseline were more likely to have a positive outcome with tCBT than persons without these characteristics. tCBT was associated with the greatest increase in quality of life and lowest costs. Cost per quality adjusted life year was £3957–£5917 depending on method of analysis. Conclusions A short course of tCBT for people with CWP was effective long-term and was highly cost-effective. Exercise was also effective but delivered positive outcome for fewer patients at greater cost, and there was no advantage for patients receiving both interventions

Application of a diagnosis-based clinical decision guide in patients with neck pain

<p>Abstract</p> <p>Background</p> <p>Neck pain (NP) is a common cause of disability. Accurate and efficacious methods of diagnosis and treatment have been elusive. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based guide in applying the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with NP.</p> <p>Methods</p> <p>Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of NP patients examined by one of three examiners trained in the application of the DBCDG.</p> <p>Results</p> <p>Data were gathered on 95 patients. Signs of visceral disease or potentially serious illness were found in 1%. Centralization signs were found in 27%, segmental pain provocation signs were found in 69% and radicular signs were found in 19%. Clinically relevant myofascial signs were found in 22%. Dynamic instability was found in 40%, oculomotor dysfunction in 11.6%, fear beliefs in 31.6%, central pain hypersensitivity in 4%, passive coping in 5% and depression in 2%.</p> <p>Conclusion</p> <p>The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability, validity and efficacy of treatment based on the DBCDG.</p

Activity pacing: moving beyond taking breaks and slowing down

This brief communication responds to the paper by Jeong and Cho (Qual Life Res 26(4):903–911, 2017) that has described activity pacing in limited terms of adjusting activities through going at a slower rate and taking breaks. Activity pacing was reported as not involving goal setting, in comparison to other strategies for long-term conditions such as Acceptance and Commitment Therapy. This brief communication aims to challenge this limited perception of activity pacing in light of numerous studies that recognise pacing to be a more complex strategy. Pacing is considered to be a multifaceted coping strategy, including broad themes of not only adjusting activities, but also planning activities, having consistent activity levels, acceptance of current abilities and gradually increasing activities, and one that includes goal setting as a key facet. It is essential that pacing is both defined and measured as a multifaceted strategy in order to assess the outcomes of pacing, and for meaningful comparisons with other strategies regarding efficacy for the management of long-term conditions

Refining and testing the diagnostic accuracy of an assessment tool (PAT-POPS) to predict admission and discharge of children and young people who attend an emergency department : protocol for an observational study

Background: Increasing attendances by children (aged 0–16 years) to United Kingdom Emergency Departments (EDs) challenges patient safety within the National Health Service (NHS) with health professionals required to make complex judgements on whether children attending urgent and emergency care services can be sent home safely or require admission. Health regulation bodies have recommended that an early identification systems should be developed to recognise children developing critical illnesses. The Pennine Acute Hospitals NHS Trust Paediatric Observation Priority Score (PAT-POPS) was developed as an ED-specific tool for this purpose. This study aims to revise and improve the existing tool and determine its utility in determining safe admission and discharge decision making. Methods/design: An observational study to improve diagnostic accuracy using data from children and young people attending the ED and Urgent Care Centre (UCC) at three hospitals over a 12 month period. The data being collected is part of routine practice; therefore opt-out methods of consent will be used. The reference standard is admission or discharge. A revised PAT-POPs scoring tool will be developed using clinically guided logistic regression models to explore which components best predict hospital admission and safe discharge. Suitable cut-points for safe admission and discharge will be established using sensitivity and specificity as judged by an expert consensus meeting. The diagnostic accuracy of the revised tool will be assessed, and it will be compared to the former version of PAT-POPS using ROC analysis. Discussion: This new predictive tool will aid discharge and admission decision-making in relation to children and young people in hospital urgent and emergency care facilities. Trial registration: NIHR RfPB Grant: PB-PG-0815-20034. ClinicalTrials.gov: 213469. Retrospectively registered on 11 April 2018. Keywords: Paediatric, Emergency department, Diagnostic accuracy, Early identification systems, screening tool, Observational, Early warning score, Early warning system, hospital admission