Evidence-based practice: attitudes, knowledge and behaviour among allied health care professionals.

OBJECTIVE: To explore dieticians', occupational therapists' and physical therapists' attitudes, beliefs, knowledge and behaviour concerning evidence-based practice within a university hospital setting. DESIGN: Cross-sectional survey. SETTING: University hospital. PARTICIPANTS: All dieticians, occupational therapists and physical therapists employed at a Swedish university hospital (n = 306) of whom 227 (74%) responded. MAIN OUTCOME MEASURES: Attitudes towards, perceived benefits and limitations of evidence-based practice, use and understanding of clinical practice guidelines, availability of resources to access information and skills in using these resources. RESULTS: Findings showed positive attitudes towards evidence-based practice and the use of evidence to support clinical decision-making. It was seen as necessary. Literature and research findings were perceived as useful in clinical practice. The majority indicated having the necessary skills to be able to interpret and understand the evidence, and that clinical practice guidelines were available and used. Evidence-based practice was not perceived as taking into account the patient preferences. Lack of time was perceived as the major barrier to evidence-based practice. CONCLUSIONS: The prerequisites for evidence-based practice were assessed as good, but ways to make evidence-based practice time efficient, easy to access and relevant to clinical practice need to be continuously supported at the management level, so that research evidence becomes linked to work-flow in a way that does not adversely affect productivity and the flow of patients.

The influence of brushing force and stroking velocity on dynamic mechanical allodynia in patients with peripheral neuropathy.

Recently we demonstrated brush-evoked allodynia to be a partially graded phenomenon since increased brushing length and number of strokes significantly increased the brush-evoked pain intensity. In this study the influence of stroking velocity and brushing force on dynamic mechanical allodynia was examined in 16 patients with peripheral neuropathy. Brush-evoked allodynia was induced by lightly stroking 60mm of the skin twice with a 16 mm wide brush while varying stroking velocity (10, 20, 30 mm/s) and brushing force (10, 20, 40 g). Intensity and duration of brush-evoked allodynia was recorded using a computerized visual analogue scale. The total brush-evoked pain intensity, including painful aftersensation was calculated as the area under the curve. Significantly increased total brush-evoked pain intensity was demonstrated with lower stroking velocity (P<0.001) and higher brushing force (P<0.05). Higher maximum pain intensity was reported with higher brushing force. In conclusion, our findings demonstrated a significant relationship between the total brush-evoked pain intensity and stroking velocity as well as brushing force. Together with previously accumulated data these results substantiate the usefulness of this semi-quantitative assessment method in longitudinal studies on dynamic mechanical allodynia.

Dynamic mechanical allodynia in the secondary hyperalgesic area in the capsaicin model-Perceptually similar phenomena as in painful neuropathy?

Introduction In order to develop valid experimental human pain models, i.e., models potentially reflecting mechanisms underlying certain expressions of clinical pain conditions, similarities and discrepancies of symptoms/signs must first and foremost be evaluated comparing the two. In a situation where symptoms/signs appear to be similar, a potential pitfall with surrogate models would be that pathophysiological mechanisms in clinical conditions and experimental models might differ, i.e., one symptom/sign may be due to several different mechanisms. Symptoms and signs caused by intradermally injected capsaicin have been suggested to reflect aspects of the clinical phenomenology of neuropathic pain, e.g., dynamic mechanical allodynia. Psychophysical characteristics of brush-evoked pain in the pain area in patients with painful peripheral neuropathy were compared with brush-evoked pain in the secondary hyperalgesic area in capsaicin-treated skin in patients and in healthy subjects using different temporo-spatial stimulus parameters. Method Nine patients were examined in the area of painful neuropathy and subsequently in the corresponding contralateral secondary site, i.e., the secondary hyperalgesic area after an intradermal capsaicin injection. Nine healthy age- and sex-matched subjects were examined in a corresponding area after capsaicin injection. Brush-evoked allodynia was induced by lightly stroking 2 different distances of the skin 2 or 4 times with brushes of 2 different widths. Intensity and duration of brush-evoked allodynia was recorded using a computerized visual analogue scale. The total brush-evoked pain intensity, including aftersensation was calculated as the area under the curve. In addition, similarities and discrepancies in the selection of sensory-discriminative and affective descriptors of the painful experience have been surveyed in the area of neuropathy and in the area of secondary hyperalgesia. Results All patients reported brush-evoked pain in their area of painful neuropathy during all stimuli. Eight out of 9 patients reported brush-evoked pain in an area outside the flare in the capsaicin treated skin and only 3 out of 9 healthy subjects reported brush-evoked pain in an area outside the flare. Within patients there was no significant difference between sides regarding the influence of the various temporo-spatial stimulus parameters on the total brush-evoked pain intensity. Of all parameters tested, only increased number of strokes resulted in significantly higher brush-evoked pain intensity. The most commonly used sensory-discriminative descriptors during brush-evoked pain in the area of painful neuropathy and in the capsaicin-induced secondary hyperalgesic area in patients and controls were smarting and burning and for the affective descriptors troublesome and annoying. Conclusions Similarities were found regarding the influence of temporo-spatial stimulus parameters on brush-evoked allodynia in the capsaicin-induced secondary hyperalgesic area contralateral to the area of painful neuropathy and their influence when testing the area of neuropathic pain. Only 3/9 healthy subjects reported brush-evoked pain after capsaicin injection, a finding that may be related to this group reporting less spontaneous pain than the patients after injection. A hyperexcitable nervous system due to the contralateral clinical condition may also have a bearing on the frequent finding of capsaicin-induced allodynia in the patients (8/9). Implications The low prevalence of tactile allodynia in healthy volunteers makes the capsaicin model an unattractive strategy.

On the repeatability of brush-evoked allodynia using a novel semi-quantitative method in patients with peripheral neuropathic pain.

Using a semi-quantitative method the repeatability of brush-evoked allodynia was examined within and between days in nine patients with spontaneous ongoing pain and dynamic mechanical allodynia due to peripheral neuropathy. In addition, the relationship between the intensity of spontaneous ongoing pain and the total brush-evoked pain intensity was addressed. The brush stimulus was applied in the innervation territory of the lesioned nervous structure by lightly stroking 60 mm of the skin four times with an 8 mm wide brush. Using a computerized visual analogue scale the patients continuously rated the intensity and duration of brush-evoked allodynia and the total brush-evoked pain intensity was calculated as the area under the curve. The patients were examined 4 days during one month, i.e. at day 1, 3, 28 and 30 and each study day the stimulus was repeated four times with an inter-stimulus interval of 10 min. The variation between repeated assessments was analyzed using the intraclass correlation coefficient and the total brush-evoked pain intensity within days ranged from 0.89 to 0.95 ("very good repeatability") and between days from 0.77 to 0.97 ("very good repeatability"). A significant positive correlation was demonstrated between the mean intensity of spontaneous ongoing pain and the mean total brush-evoked pain intensity (r(s)=0.68, P<0.042, "a moderate to good correlation").

Dynamic mechanical allodynia: on the relationship between temporo-spatial stimulus parameters and evoked pain in patients with peripheral neuropathy.

The relationship between temporo-spatial stimulus parameters and evoked pain intensity as well as duration was examined in patients with peripheral neuropathy and brush-evoked allodynia, i.e. dynamic mechanical allodynia. Brush-evoked allodynia was induced in the innervation territory of the lesioned nervous structure in 18 patients by lightly stroking different distances of the skin (20, 40, 60 mm) two or four times with brushes of different widths (4, 8, 16 mm). Pain intensity and duration of brush-evoked allodynia was recorded using a computerized visual analogue scale. The total brush-evoked pain intensity, including painful aftersensation was calculated as the area under the curve. Following each stimulus, the patients selected pain descriptors from a validated instrument. Significantly increased total brush-evoked pain intensity was demonstrated with increased brushing length and number of strokes (P<0.001), but not while altering brush width. Lack of influence of brush width was further underlined by the finding that activation of equivalent areas (e.g. 160 mm2) resulted in higher total brush-evoked pain intensity if brushing the skin with a thin brush (4 mm) over a longer distance (40 mm) than a thick brush (8 mm) over a shorter distance (20 mm). Significantly increased duration of aftersensation was demonstrated only following increased brushing length (P<0.008). The most commonly used sensory-discriminative pain descriptors were pricking, burning and sore and for the affective descriptors, annoying and troublesome. This is the first study demonstrating a relationship between evoked pain and some temporo-spatial stimulus parameters during brush-evoked allodynia.