Content Analysis of General Practitioner Requested Lumbar Spine X-ray Reports

Aims and Background X-rays of patients with low back pain rarely show serious pathology but frequently reveal incidental age-related changes and always expose people to radiation. Patients who have X-rays are more satisfied but report worse pain and disability. Psychological factors such as illness beliefs,catastrophizing and fear avoidance have been shown to be predictors of chronicity/disability. Authorities suggest that the way X-ray information is transmitted and interpreted by patients may influence outcome, therefore this study was designed to determine the words used by radiologists to describe lumbar spine Xrays. Methods: 120 consecutive X-ray reports for patients referred by primary care physicians were anonymised. A formal summative content analysis was undertaken. The coded words were grouped into categories according to their perceived meaning, and the process was refined until there were only three mutually exclusive categories. Results: Half the sample was aged 60 years or younger. Three categories were identified: anatomical, pathological and descriptive. In the pathological category, 33% of words described normal appearances, 47% described age-related changes and 20% described other features. In only 2% of cases were pathological words used to describe conditions as being "normal for age". Overall, 89 (74%) of the 120 reports contained at least one phrase containing words indicating the presence of degenerative changes. Conclusions: Almost three-quarters of lumbar spine X-ray reports use pathological words such as 'degenerative changes' to describe age-related changes but rarely describe them as being "normal for age"

Exploring joint hypermobility syndrome, developmental coordination disorder and pain

INTRODUCTION Floppy, clumsy, hypermobile children are increasingly referred to occupational and physical therapy under the label of dyspraxia. Motor impairments associated with the umbrella diagnosis of developmental coordination disorder (DCD) have been reported as persisting into adolescence and adulthood and subsequently affecting functional abilities (Cousins and Smyth 2003). Within this heterogeneous condition the underlying mechanisms causing the motor difficulties remains unclear. Ayers (1985) hypothesised that some individuals might have somatosensory processing issues contributing to their poor motor planning and coordination difficulties. Similarities in functional difficulties have been noted in children with a diagnosis of DCD and joint hypermobility syndrome (JHS) (Kirby and Davies 2006). There is limited understanding of the relationship between the two conditions. JHS is a multisystemic inherited connective tissue disorder, in which hypermobile joints, pain, clumsiness, poor proprioception and dislocations are familiar features (Grahame and Hakim 2006; Adib et al 2005). It has been suggested that adults with JHS show poor movement patterns which contribute to biomechanical dysfunction and continuing pain (Clark et al 2009). Pain and disability reported in adults with JHS often leads to anxiety, depression, work incapacity and social isolation (Grahame and Hakim 2006). The purpose of this study was to explore the association between adults with JHS and DCD and long term pain. METHODOLOGY/ METHODS A mixed methods design influenced by a pragmatic paradigm was utilised. Subjects: 90 patients with JHS (18-65 years) recruited from a hypermobility clinic were compared, using a questionnaire, with 113 healthy volunteers (18-65 years) with no pain recruited from a university. Analysis: Quantitative data were described and examined by regression, odds ratios were calculated. Qualitative data was analysed thematically FINDINGS The percentage of subjects who reported DCD in patients with JHS and healthy volunteers were 56% and 19% respectively. A significant association between patients with JHS and DCD was noted, chi square = 30.11, p < .001. Patients with JHS were 6 times [95% CI 2.9 – 10.3] more likely to report DCD than healthy volunteers. Pain was a significant feature with an average of 9.8 pain sites reported (out of a total of 17). Open ended questions revealed many patients recalling pain starting in early childhood and adolescence. DISCUSSION These results suggest a significant association between patients with JHS and DCD and the reporting of long term pain. Early recognition and understanding of the needs of children with DCD who present with somatosensory impairment, pain modulation and JHS is therefore essential. Sensory integration therapy as part of a comprehensive early intervention program has the potential to mitigate long term problems. A multidisciplinary approach which involves health professionals and teachers is also recommended. CONCLUSION This research may be considered an early step in the identification of an association of DCD and JHS. Further studies are required to explore somatosensory processing issues experienced by those with DCD and JHS as this might be an important underlying mechanism

New knowledge for advancing practice in pain management

This chapter contains sections titled: Introduction Advancing practice in pain management Conclusions Reference

Abstract: Pain poses a significant health burden in those with Joint Hypermobility Syndrome

Background Joint hypermobility Syndrome (JHS) is a complex multisystemic connective tissue disorder. JHS is acknowledged as a common clinical entity in musculoskeletal medicine with a prevalence of between 30%-60% in those presenting with musculoskeletal pain. It is more prevalent in females than males may present in childhood and shares symptom overlap with Ehlers-Danlos Syndrome, Marfan Syndrome and Ostegenesis Imperfecta. Patients with JHS report a variety of symptoms associated with this condition. These symptoms include: chronic pain, dislocations, impaired coordination, autonomic nervous system (ANS) and Gastrointestinal (GI) symptoms. Aims The purpose of this study was to investigate the health burden in those with JHS and to understand which symptoms are considered to be most troublesome. Methods A sample of 89 patients with JHS (mean age 34.6 ± 9.9 years, 82 female), diagnosed by a consultant rheumatologist according to the Brighton Criteria were compared with 113 healthy volunteers (mean age 35.7 ± 12.9, 82 female) with no musculoskeletal pain. Information relating to dislocations, ANS, GI symptoms and impaired coordination was collected by means of a self-report questionnaire. Data relating to the reporting of pain for >3 months was collected on a pain chart and the SF-12 was employed for assessing quality of life. SF-12 data is reported as Physical Component Summary (PCS) scores and Mental Component Summary (MCS) Scores. A difference in either the PCS or MCS scores of 5 points is considered to be a clinically important difference. Numerical data were analysed using independent sample t-tests and regression analysis. Results Patients with JHS reported significantly lower mean PCS scores (M = 29.70 SD 10.63) than healthy volunteers (M = 54.45 SD 5.74), t (127.701) = 19.81, p<0.001 (2-tailed). The mean difference was 24.75 points [95%CI 22.44 - 27.06] - a statistically significant and clinically important difference. Patients with JHS were significantly more likely to report the following than healthy volunteers; subluxations/dislocations, GI and ANS symptoms and impaired coordination. The average number of pain sites reported was 10/17. Regression analysis of the reported symptoms revealed the number of pain sites as the only significant predictor of a lowered PCS score (p< 0.01) in a model explaining 23% of the variance. MCS scores of patients with JHS (M = 41.13 SD 11.60) were significantly lower than those of healthy volunteers (M = 45.64 SD 10.95), t (200) = 2.65, p<0.01. The mean difference was <5 points - this might not be clinically important. Conclusion Patients with JHS in this study reported a statistically significant reduction in both PCS and MCS scores compared with healthy volunteers. The large difference in PCS scores is likely to be clinically important. Although multisystemic symptoms were reported multisite pain was the only symptom which contributed significantly to a lowered PCS score of the SF-12. This study high lights the health and personal burden of those with JHS and the importance of recognising and understanding the contribution of multisite pain in this population

An Exploration of Neurophysiological Symptoms in Patients with Joint Hypermobility Syndrome and their Impact on Quality of Life.

Purpose: The purpose of this study was to explore the prevalence of neurophysiological symptoms in patients with Joint Hypermobility Syndrome (JHS) and their impact on quality of life. Relevance: Clinical experience suggests patients with JHS suffer from neurophysiological symptoms contributing to skill and health impairments affecting quality of life. MethodsA sample of 90 JHS-patients (mean age 34.7 ± 9.9 years), diagnosed according to the Brighton Criteria were compared with 113 healthy volunteers (mean age 35.7 ± 12.9) with no musculoskeletal pain. Neurophysiological symptoms were collected in a self report questionnaire. The Functional Difficulties Questionnaire was used for the assessment of developmental coordination disorder (DCD). A pain chart was employed to collect data relating to musculoskeletal pain. The SF-12 medical outcomes questionnaire was used for assessing quality of life. Analysis: Chi-square was employed to compare group proportions. Continuous numerical data comparisons were analysed using independent sample t-tests. Regression analysis was employed to analyse multiple variables. Results: Patients with JHS were significantly more likely to report the following than healthy volunteers; autonomic symptoms (70%, 12%); gastrointestinal symptoms (71%, 9%); DCD (56%, 19%) and chronic fatigue syndrome (31%, 1%). The mean number of pain sites reported for patients with JHS were 9.83 ± 4.18. Patients with JHS reported significantly lower physical component summary scores (PCS) of the SF-12 than healthy volunteers (p < 0.001). Pain was a significant predictor of reduced PCS of the SF-12 (p < 0.001) in a model that explained 23% of the variance. Conclusions Neurophysiological symptoms were common. Pain was a significant contributor to the health burden of patients with JHS. Research is required to explore the connectivity and implications of these symptoms in relation to the central nervous system. Implications: There is a requirement to acknowledge and understand the multidimensional nature of JHS

Patient experiences of anxiety, depression and acute pain after surgery: a longitudinal perspective

This study sought to explore the impact of the psychological variables anxiety and depression, on pain experience over time following surgery. Eighty-five women having major gynaecological surgery were assessed for anxiety, depression and pain after surgery. To gain further understanding, 37 patients participated in a semi-structured taped telephone interview 4–6 weeks post-operatively. Pre-operative anxiety was found to be predictive of post-operative anxiety on Day 2, with patients who experienced high levels of anxiety before surgery continuing to feel anxious afterwards. By Day 4 both anxiety and depression scores increased as pain increased and one-third of the sample experienced levels of anxiety in psychiatric proportions whilst under one-third experienced similar levels of depression. These findings have significant implications for the provision of acute pain management after surgery. Future research and those managing acute pain services need to consider the multidimensional effect of acute pain and the interface between primary and secondary care

‘Trying to pin down jelly’ - exploring intuitive processes in quality assessment for meta-ethnography

Background: Studies that systematically search for and synthesise qualitative research are becoming more evident in health care, and they can make an important contribution to patient care. However, there is still no agreement as to whether, or how we should appraise studies for inclusion. We aimed to explore the intuitive processes that determined the ‘quality’ of qualitative research for inclusion in qualitative research syntheses. We were particularly interested to explore the way that knowledge was constructed. Methods: We used qualitative methods to explore the process of quality appraisal within a team of seven qualitative researchers funded to undertake a meta-ethnography of chronic non-malignant musculoskeletal pain. Team discussions took place monthly between October 2010 and June 2012 and were recorded and transcribed. Data was coded and organised using constant comparative method. The development of our conceptual analysis was both iterative and collaborative. The strength of this team approach to quality came from open and honest discussion, where team members felt free to agree, disagree, or change their position within the safety of the group. Results: We suggest two core facets of quality for inclusion in meta-ethnography - (1) Conceptual clarity; how clearly has the author articulated a concept that facilitates theoretical insight. (2) Interpretive rigour; fundamentally, can the interpretation ‘be trusted?’ Our findings showed that three important categories help the reader to judge interpretive rigour: (ii) What is the context of the interpretation? (ii) How inductive is the interpretation? (iii) Has the researcher challenged their interpretation? Conclusions: We highlight that methods alone do not determine the quality of research for inclusion into a meta-ethnography. The strength of a concept and its capacity to facilitate theoretical insight is integral to meta-ethnography, and arguably to the quality of research. However, we suggest that to be judged ‘good enough’ there also needs to be some assurance that qualitative findings are more than simply anecdotal. Although our conceptual model was developed specifically for meta-ethnography, it may be transferable to other research methodologies

Managing for climate resilient fisheries: Applications to the Southern Ocean

Climate change is having profound effects on populations of fished species and the ecosystems on which they depend, lending to a growing body of work that advocates for climate resilience to be a priority in fishery management. Here, we provide a comprehensive analysis of the tools needed to manage for climate resiliency. The Antarctic region is among the most vulnerable to climate change, and thus, we then consider climate resilient management tools utilized by the Commission for the Conservation of Antarctic Marine Living Resources (CCAMLR), the body responsible for the management of Antarctic marine living resources as part of the Antarctic Treaty System. We note progress, gaps, and opportunities for implementation. Across the literature, ecosystem-based management was cited as an appropriate tool for climate resilience of marine ecosystems, as was the use of climate model outputs (projections and simulations), marine protected areas (MPAs), and dynamic stock assessments. CCAMLR has a unique position where its Convention effectively mandates the principles of an ecosystem-based precautionary approach for managing fisheries, and many of its Member States have been advocating for climate initiatives within this approach. While CCAMLR has made limited overall progress towards ensuring climate resilience, it has advanced in some areas, such as MPA implementation, developing a risk assessment for krill, and including statements on climate change in fishery reports, although there is much work to be done. While climate change remains a worldwide issue that must be addressed on a global scale, CCAMLR holds the responsibility for adaptively managing Southern Ocean marine living resources for climate resilience