An exploration of low back pain beliefs held by health care professionals in Northern America.

BACKGROUND: Prior research demonstrated that people in the United States and Canada (Northern America) hold predominantly biomedical beliefs about Low back pain (LBP); such beliefs were attributed to healthcare professionals (HCP). Further investigation is needed to understand HCP' LBP beliefs, preferred management strategies, and sources of beliefs. METHODS: Participants were recruited via social media to complete a qualitative cross-sectional online survey. The survey was distributed to assess LBP beliefs in a U.S. and Canadian-based clinician population. Participants answered questions about the cause of LBP, reasons for recurrence or persistence, use of imaging, management strategies, and sources of beliefs. Responses were analysed using an inductive thematic analysis. RESULTS: One hundred and sixty three participants were included, reporting multiple causes for LBP. However, many references were anchored to biological problems. When psychological variables were mentioned, it typically involved patient blaming. Like prior research studies, minimal attention was given to societal and environmental influences. Management strategies often aligned with guideline care except for the recommendation of inappropriate imaging and a reliance on passive interventions. CONCLUSIONS: These findings align with prior research studies on general population beliefs, demonstrating a preference for biological causes of LBP. Further updates are needed for clinical education, while future studies should seek to assess the translation of clinician beliefs into clinical practice and health system constraints.

Person-centred management of upper limb complex regional pain syndrome: an integrative review of non-pharmacological treatment.

Introduction: Complex Regional Pain Syndrome (CRPS) is most common in the upper limb and associated with high disability. The purpose of this review was to critically appraise and synthesise literature exploring non-pharmacological treatment for upper limb CRPS, to guide upper-limb-specific management. Methods: Using an integrative review methodology, 13 databases were searched to identify all published studies on non-pharmacological management of upper limb CRPS. The Crowe Critical Appraisal Tool was used to provide quality ratings for included studies, and analysis employed a qualitative descriptive approach. Results: From 236 abstracts reviewed, 113 full texts were read, and 38 articles selected for data extraction. Designs included single case (n = 14), randomised controlled trial (n = 8), prospective cohort (n = 8), case series (n = 4), retrospective (n = 3), and mixed methods (n = 1). Interventions were categorised as sensory retraining (n = 13), kinesiotherapy (n = 7), manual therapies (n = 7), physical modalities (n = 6), and interdisciplinary treatment programmes (n = 5). All studies measured pain intensity, and most (n = 24) measured physical parameters such as strength, movement, or perceptual abilities. Few measured patient-rated function (n = 13) or psychological factors (n = 4). Quality ratings ranged from 30% to 93%, with a median of 60%. Conclusion: Methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor. Movement, desensitisation, and graded functional activity remain the mainstays of intervention. However, despite the impact of CRPS on wellbeing and function, psychological factors and functional outcomes are infrequently addressed. Further robust research is required to determine which aspects of treatment have the greatest influence on which symptoms, and when and how these should be introduced and progressed.

Experiences of diagnosis and treatment for upper limb Complex Regional Pain Syndrome: a qualitative analysis.

INTRODUCTION: Complex Regional Pain Syndrome (CRPS) most frequently affects the upper limb, with high associated disability. Delays to diagnosis and appropriate treatment can adversely impact prognosis and quality of life, but little is known about the healthcare experiences of people with CRPS. This study aimed to explore lived experiences of diagnosis and treatment for people with upper limb CRPS. METHODS: Participants were recruited through online support groups and multiple public and private healthcare settings in the Greater Wellington Region, New Zealand. Semi-structured interviews were conducted with participants who had experienced upper limb CRPS for more than three months and less than three years. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS: Thirteen participants (11 female, 2 male) aged between 43 and 68 years were interviewed. Duration of CRPS ranged from 7 months to 2.5 years. Five themes were identified. Participants initially engaged in healthcare out of a desire to return to being the person they were before having CRPS. Three interacting experiences epitomised the overall healthcare experience: (1) not knowing what is going on, (2) not being taken seriously, and (3) healthcare as adding another layer of load. Meanwhile, participants used multiple approaches in an attempt to not let CRPS stop them from continuing to live their lives. CONCLUSIONS: Participants in this study felt that credible information, validation, and simplification from healthcare providers and systems would support their process of navigating towards a meaningful life and self-concept in the presence of CRPS.

Features and methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a Delphi expert consensus study.

ABSTRACT: Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain.

Evaluating sensory profiles in nociplastic chronic low back pain: a cross-sectional validation study.

BACKGROUND: Sensory profiles (SPs) may be useful in classifying patients based on sensory sensitivity and behavioral responses to stimuli to develop personalized treatments for nonspecific chronic low back pain (CLBP). The Adolescent/Adult Sensory Profile (AASP) identifies four sensitivity and behavioral response-related quadrants: Sensory Sensitive, Sensation Avoiding, Low Registration, and Sensation Seeking. It is an appropriate questionnaire for evaluating SPs; however, it has not been validated in CLBP. OBJECTIVES: To assess the internal consistency, test-retest reliability, agreement, and construct validity of the AASP in a CLBP population with nociplastic pain in primary care physiotherapy. DESIGN: Two evaluations were performed at a 2-week interval in this non-experimental cross-sectional study. PARTICIPANTS: Patients with CLBP. METHODS: Questionnaires were used to compare outcomes with the AASP. Reliability was evaluated by assessing internal consistency and test-retest reliability. Construct validity was evaluated in response to the a priori hypothesis. RESULTS: Ninety patients with CLBP were included. Internal consistency was excellent for all SPs (Cronbach's alpha, 0.91-0.92). Test-retest reliability Intraclass Correlation Coefficient (ICC (3,2)) 0.82-0.87, for the SPs (95% CI 0.74-0.91, p< .001). Construct validity correlated positively with Low Registration, Sensory Sensitive, and Sensation Avoiding and negatively with Sensation Seeking. CONCLUSION: The AASP is suitable for evaluating SPs in primary care CLBP patients.

Consider the context: An analysis of personal social networks of caregivers of children participating in a paediatric weight management program.

Social networks influence the health and well-being of children and families. This study aimed to identify and understand the social networks of caregivers of children participating in the KidFit Health and Wellness Clinic, a paediatric weight management program. An egocentric social network analysis was used. Caregivers with children enrolled in KidFit participated in semi-structured interviews by completing a personal network map and discussing the individuals in their social networks and their influence on them and their family. Twenty-two caregivers (90.9% mothers) completed the interview. Four structural patterns were identified within the networks: existence of a core, star-shaped network, well-connected network and existence of multiple clusters. Healthcare providers and family had the most influence within the caregivers' networks. With the exception of healthcare providers, individuals who communicated less frequently with caregivers tended to have less influence on caregivers. Internet resources, activity-related resources and social media were the top three services, resources or supports that caregivers reported accessing. It is important that practitioners working with children and families within paediatric settings recognize the unique sociocultural context of each family. Reconceptualising a care model that includes community and incorporates services, supports and resources beyond the clinic could enhance treatment.

Nortriptyline for pain in knee osteoarthritis: a double-blind randomised controlled trial in New Zealand general practice.

BACKGROUND: Osteoarthritis (OA) of the knee is a common cause of chronic pain. Analgesics that are currently available have limited efficacy and may be poorly tolerated. Tricyclic antidepressants are used as analgesics for other chronic conditions, but they have not been evaluated as analgesics in OA. AIM: To investigate the analgesic efficacy of nortriptyline in people with knee OA. DESIGN AND SETTING: A two-arm, parallel-group, 1:1, double-blind, randomised, placebo-controlled trial in Christchurch, New Zealand. METHOD: Participants were recruited from orthopaedic outpatient clinics, primary care, and through public advertising. Adults with knee OA and a pain score of ≥20 points on the 50-point Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain subscale were randomised to receive either nortriptyline or identical placebo for 14 weeks. The primary outcome was knee pain at 14 weeks measured using the WOMAC pain subscale. Secondary outcomes included: function; stiffness; non-steroidal anti-inflammatory drug, opioid, and/or paracetamol use; each participant's global assessment; and adverse effects at 14 weeks. RESULTS: Of the 205 randomised participants, 201 (98.0%) completed follow-up at 14 weeks. The baseline-adjusted mean WOMAC pain subscale score at week 14 was 6.2 points lower (95% confidence interval = -0.26 to 12.6, P = 0.06) in the nortriptyline arm versus the placebo arm. Differences in secondary outcomes generally favoured the nortriptyline arm, but were small and unlikely to be clinically relevant. However, the following were all more commonly reported by participants taking nortriptyline than those taking a placebo: dry mouth (86.9% versus 51.0%, respectively, P<0.001), constipation (58.6% versus 30.4%, respectively, P<0.001), and sweating (31.3% versus 20.6%, respectively, P = 0.033). CONCLUSION: This study suggests nortriptyline does not significantly reduce pain in people with knee OA. The adverse effect profile was as expected.

Validity of the Ages and Stages Questionnaire to identify young children with gross motor difficulties who require physiotherapy assessment.

AIM: To determine if the Ages and Stages Questionnaire, Third Edition Gross Motor domain (ASQ-3-GM) score is predictive of motor performance on the Alberta Infant Motor Scale (AIMS) and/or Neurological, Sensory, Motor, Developmental Assessment (NSMDA). METHOD: This was a cross-sectional study involving analysis of a 1-year consecutive clinical sample of data obtained from children attending a specialist public outpatient service. Participants were 84 children aged 0 to 5 years (mean age 24.9mo, SD 18.4mo; 50 males, 34 females) referred for physiotherapy assessment of gross motor skills in a tertiary child development service. Parents completed the ASQ-3 questionnaire and children were assessed using the AIMS (if aged 0-18mo) and/or NSMDA (all children). To determine possible relationships between ASQ-3-GM scores with AIMS and NSMDA scores, we calculated Spearman's rank correlation coefficients. To determine validity of the ASQ-3-GM 'refer for further assessment' ('refer') cut-off score to identify gross motor difficulties we calculated frequency distributions and crosstab analyses. RESULTS: ASQ-3-GM scores correlated with AIMS centile rank (r=0.697, p<0.001) and NSMDA motor performance classification (r=-0.548, p<0.001). The ASQ-3-GM 'refer' cut-off had 77% sensitivity, 91% specificity, and 95% positive predictive value (PPV) to identify children that scored ≤10th centile on the AIMS and 57% sensitivity, 92% specificity, and 97% PPV to identify children with at least minimal dysfunction on the NSMDA. INTERPRETATION: The ASQ-3-GM 'refer' cut-off score is a valid predictor of gross motor difficulties in young children. WHAT THIS PAPER ADDS: The Ages and Stages Questionnaire, Third Edition Gross Motor domain (ASQ-3-GM) score is valid to identify gross motor difficulties in young children. The ASQ-3-GM 'refer' cut-off had 95% positive predictive value (PPV) for children that scored ≤10th centile on the Alberta Infant Motor Scale. The ASQ-3-GM 'refer' cut-off had 97% PPV for at least minimal dysfunction on the Neurological, Sensory, Motor, Developmental Assessment.

Validez del Cuestionario de Edades y Etapas para identificar a niños pequeños con dificultades motoras gruesas que requieren evaluación de fisioterapia OBJETIVO: Determinar si el puntaje del Cuestionario de Edades y Etapas, dominio de Motricidad Gruesa de la Tercera Edición (ASQ-3-GM) es predictivo del rendimiento motor en la Escala Motora Infantil de Alberta (AIMS) y / o Evaluación Neurológica, Sensorial, Motora y de Desarrollo (NSMDA) ) MÉTODO: Este fue un estudio transversal que incluyó el análisis de una muestra clínica consecutiva de 1 año de datos obtenidos de niños que asistían a un servicio público ambulatorio especializado. Los participantes fueron 84 niños de 0 a 5 años (edad media 25m, DE 18m; 50 varones, 34 mujeres) remitidos para evaluación de fisioterapia de habilidades motoras gruesas en un servicio de desarrollo infantil de tercer nivel. Los padres completaron el cuestionario ASQ-3 y los niños fueron evaluados utilizando el AIMS (si tenían entre 0 y 18 meses) y / o NSMDA (todos los niños). Para determinar las posibles relaciones entre las puntuaciones ASQ-3-GM con las puntuaciones AIMS y NSMDA, calculamos los coeficientes de correlación de rango de Spearman. Para determinar la validez del ASQ-3-GM "remítase a una puntuación de corte de evaluación adicional" ("refiérase") para identificar dificultades motoras graves, calculamos distribuciones de frecuencia y análisis de tabla cruzada. RESULTADOS: Las puntuaciones ASQ-3-GM se correlacionaron con el rango de percentiles AIMS (r = 0.697, p <0,001) y la clasificación de rendimiento motor NSMDA (r = -0,548, p <0,001). El límite de 'referencia' ASQ-3-GM tenía 77% de sensibilidad, 91% de especificidad y 95% de valor predictivo positivo (VPP) para identificar a los niños que obtuvieron ≤10 percentil en el AIMS y 57% de sensibilidad, 92% de especificidad, y 97% de VPP para identificar a niños con disfunción mínima en el NSMDA. INTERPRETACIÓN: La puntuación de corte ASQ-3-GM 'referido' es un predictor válido de dificultades motoras gruesas en niños pequeños.

Validade do Questionário Idades e Fases para identificar crianças pequenas com dificuldades motoras que precisam de avaliação fisioterapêutica OBJETIVO: Determinar se a pontuação no Questionário de Idades e Fases, Terceira edição domínio Motor Grosso (ASQ-3-MG) é preditiva do desempenho moor segundo a Escala Motora Infantil de Alberta (AIMS) e /ou da Avaliação do Desenvolvimento Neurológico, Sensorial e Motor (NSMDA). MÉTODO: Este foi um estudo transversal envolvendo análise por um ano consecutivo de uma amostra clínica de dados obtidos de crianças frequentando um serviço ambulatorial especializado público. Participantes foram 84 crianças com idades de 0 a 5 anos (média de idade 25m, DP 18m; 50 do sexo masculino, 34 do sexo feminino) encaminhados para avaliação de fisioterapia das habilidades motoras grossas em um serviço terciário de desenvolvimento infantil. Os pais completaram o questionário ASQ-3 e as crianças foram avaliadas com a AIMS (se idade de 0-18m) e/ou NSMDA (todas as crianças). Para determinar possíveis relações entre escores ASQ-3-MG com escores AIMS e NSMDA, calculamos coeficientes de correlação de Spearman. Para determinar a validade do escore de corte do ASQ-3-MG para 'encaminhar para melhor avaliação' ('encaminhar) em identificar dificuldades motoras grossas, calculamos distribuições de frequências e análises cruzadas. RESULTADOS: Os escores ASQ-3-MG se correlacionaram com os percentis AIMS (r=0,697, p<0,001) e a classificação do desempenho motor segundo a NSMDA (r=-0,548, p<0,001). O escore de corte do ASQ-3-MG 'encaminhar' teve 77% de sensibilidade, 91% de especificidade , e 95% de valor preditivo positivo (VPP) para identificar crianças com percentil ≤10º na AIMS e 57% de sensibilidade, 92% de especificidade, e 97% VPP para identificar crianças com disfunção pelo menos mínima no NSMDA. INTERPRETAÇÃO: O escore de corte do ASQ-3-GM 'encaminhar' é um preditor válido de dificuldades motoras em crianças pequenas.

Living well with chronic pain: a classical grounded theory.

Purpose: There is little theory to explain how and why some people cope well despite chronic pain. This study proposes a mid-level theoretical explanation for those that cope well, shedding light on factors relevant to acceptance.Method: Classical grounded theory methodology was closely followed to generate a theory grounded in data obtained from community-dwelling people self-identified as living well despite chronic pain.Results: The main concern of people experiencing chronic pain is resolving the problem of disrupted self-coherence. Resolution involves re-occupying self by (1) making sense of pain using an idiographic model; (2) deciding to turn from patient to person, facilitated or hindered by interactions with clinicians and occupational drive; and (3) flexibly persisting, where occupational engaging and coping allow individuals to develop future plans.Conclusions: This theory demonstrates the importance of engaging in occupation during rehabilitation by framing chronic pain adjustment within a process of renegotiating the self-concept. Occupations allow individuals to express values important to their sense of self. Coping strategies are used to enable occupation and are judged by their workability in this context. When developing goals and plans with people living with pain, rehabilitation professionals should consider an individual's position within the processes involved in learning to live well.Implication for rehabilitationLiving well with chronic pain involves a process of making sense, deciding to move on with life, and flexibly persisting.Diagnosis should be accompanied by messages about hurt and harm not being equivalent, and the need for a lifelong approach to managing a chronic problem.An idiographic depiction or formulation of a person's pain and disability provides opportunities for making sense of symptoms and collaborating on treatment goals.Remaining supportive, providing "small acts" demonstrating that the person is unique and being thought of, and encouraging engagement in valued occupations allows patients to experiment with, and start to engage in what is important in their lives.Clinicians should help people extend their coping repertoire and encourage flexibility with how these are applied in the pursuit of valued occupations.The positive motivation that comes from individuals identifying highly valued occupations is an aspect that all clinicians, but particularly occupational therapists, should recognize.

Development and Reliability of an Appropriateness and Prioritization Instrument for Eye Care Practice: A Modified Delphi Process.

Purpose: To modify the Western Canada Waiting List Project (WCWLP) cataract prioritization criteria into measurement instruments for assessing appropriateness and prioritization emphasizing health-related quality of life (HRQoL) and examining reliability.Methods: A modified Delphi process was conducted using two rounds of online surveys and a face-to-face meeting. A panel of eye care experts rated the relevancy of criteria on a 5-point scale. Patient narratives highlighted the patient experience. A G-theory framework was used to assess inter- and intra-rater agreement using the criteria.Results: Nine Ophthalmologists, three Optometrists, and one General Practitioner participated in the modified Delphi process. Consensus to include/exclude was reached on all criteria. Seventeen criteria were included and 16 were excluded. The most significant changes were related to the categorization of comorbidities and expansion of HRQoL questions. The overall reliability was good (ϕ = 0.852).Conclusion: The WCWLP was modified to include appropriateness and to better reflect HRQoL. Having achieved consensus and demonstrated reliability of the criteria, the next step is to estimate weights for criteria and to validate against patient health outcomes data.

Using cannabis for pain management after spinal cord injury: a qualitative study.

Study design: A descriptive qualitative study. Objectives: To explore why individuals with spinal cord injury (SCI) choose to use cannabis to manage their pain and their experiences in doing so. Setting: Community-dwelling adults with SCI in New Zealand. Methods: Semi-structured interviews were conducted with individuals who had a SCI, experienced pain, and self-reported use of cannabis to manage their pain. Interviews were recorded, transcribed, and subject to thematic analysis. Results: Eight individuals participated in this study. We interpreted six themes that captured the participants' perspectives regarding their choice to, and perceptions of, using cannabis to manage SCI pain. Participants were motivated to use cannabis when other pain management strategies had been ineffective and were well-informed, knowledgeable cannabis consumers. Participants reported cannabis reduced their pain quickly and enabled them to engage in activities of daily living and participate in life roles without the drowsiness of traditional prescribed pain medication. Despite the positive aspects, participants were concerned about the irregularity of supply and inconsistent dosage. Conclusions: Findings show that cannabis is used to reduce pain after SCI and enable increased community participation. Findings suggest that future studies examining the efficacy of cannabinoids in managing pain include function and participation outcome measures rather than solely focusing on measuring pain intensity. Focusing on meaningful outcomes may contribute to a greater understanding of the experiences of people with SCI.

Living with osteoarthritis is a balancing act: an exploration of patients' beliefs about knee pain.

BACKGROUND: This study aimed to explore the beliefs of people with knee osteoarthritis (OA) about the disease, and how these beliefs had formed and what impact these beliefs had on activity participation, health behaviour, and self-management. METHODS: Semi-structured interviews were conducted with 13 people with knee OA recruited from general practices, community physiotherapy clinics, and public advertisements in two provinces of New Zealand. Data were analysed using Interpretive Description. RESULTS: Two key themes emerged. 1) Knowledge: certainty and uncertainty described participants' strong beliefs about anatomical changes in their knee. Participants' beliefs in a biomechanical model of progressive joint degradation often appeared to originate within clinical encounters and from literal interpretation of the term 'wear and tear'. These beliefs led to uncertainty regarding interpretation of daily symptoms and participants' ability to influence the rate of decline and certainty that joint replacement surgery represented the only effective solution to fix the damaged knee. 2) Living with OA described broader perspectives of living with OA and the perceived need to balance competing values and risks when making decisions about activity participation, medication, attentional focus, accessing care, and making the most of today without sabotaging tomorrow. Misunderstandings about knee OA negatively impacted on activity participation, health behaviours, and self-management decisions. CONCLUSION: Biomechanical models of OA reduced participant exploration of management options and underpinned a perceived need to balance competing values. Improved information provision to people with knee OA could help guide positive health behaviour and self-management decisions and ensure these decisions are grounded in current evidence.

Nortriptyline in knee osteoarthritis (NortIKA Study): study protocol for a randomised controlled trial.

BACKGROUND: Osteoarthritis (OA) is a common cause of pain and disability. Currently available analgesics are often insufficiently effective or have unacceptable adverse effects. Tricyclic antidepressants may offer a useful centrally-acting analgesic. Nortriptyline is a readily-available, cheap and comparatively well-tolerated tricyclic antidepressant. METHODS/DESIGN: We will conduct a parallel group, two-arm, participant and investigator-blinded, randomised controlled superiority trial comparing nortriptyline with placebo. Two hundred participants with primary knee OA will be enrolled. Participants will take study medication for 14 weeks. The primary outcome is difference between treatment arms in mean pain score measured on the Western Ontario and McMaster Universities (WOMAC) pain scale at 14 weeks. DISCUSSION: This protocol describes the first randomised controlled trial of a tricyclic antidepressant in the treatment of OA. The results of the study may have significant implications for the management of this common and painful condition. TRIAL REGISTRATION: The trial was registered with the Australian New Zealand Clinical Trials Registry on 27 June 2014. The trial registration number is: ACTRN12614000683639 .

Patient expectations for chronic pain management.

INTRODUCTION: In New Zealand, one in six people report chronic pain, but the literature indicates only a 30% pain reduction is typically achieved in about half of treated patients. Most patients expecting a cure of their pain, or even substantial pain reduction, are therefore likely to be disappointed. It is important to align patient expectations with this reality. METHODS: This study analysed the responses of 250 patients referred to a Pain Management Centre to the free-text question: 'What are your main goals or reasons for attending the Pain Management Centre?' Free-text comments were analysed using ethnographic content analysis, an inductive approach in which the themes and subthemes are not predetermined, but emerge from the data during analysis, and thus reflect the issues of importance to patients themselves. FINDINGS: Three themes emerged from the analysis: patients' desire to understand their pain, regain 'normality', and concerns about medication. Responses were divided into those with an expectation of cure, and those who seemed to be more accepting of their pain and who desired management. CONCLUSION: Patients hope to return to what they perceive as normal and to have clear, relevant information about their diagnosis, prognosis and medications. Those desiring cure, or significant pain reduction, present more of a challenge to their general practitioners and the Pain Management Centre. When referring a patient for chronic pain management, there is a need to align patient expectations at the point of referral with what can realistically be achieved.