Ulysses: the effectiveness of a multidisciplinary cognitive behavioural pain management programme-an 8-year review.

OBJECTIVES: To characterise a cohort of patients with chronic pain registered to the Ulysses cognitive behavioural pain management programme (CBT-PMP) and to evaluate the effectiveness of the CBT-PMP 6 months post-discharge. METHODS: A review of patients referred to the Ulysses CBT-PMP from 2002 to 2010 was undertaken. The profile of patients was established. Domains measured included pain, physical and psychological function. Relationships between these factors were explored. Clinically significant changes in outcome measures were established at the 6-month follow-up. RESULTS: In total 553 patients registered to the CBT-PMP, pre-post data were available for 91 % of patients and 52 % at 6 months. The majority of patients were female and aged between 40 and 50 years. Most patients had significant psychological morbidity (76 % depression, 84.5 % anxiety), moderate reports of pain [numerical rating scale, mean (SD) 6.0 (2.2)], and low levels of functional activity. At 6 months follow-up, statistically significant positive findings for physical and psychological outcome measures are supplemented by results showing their clinical significance. With regard to psychological function, a clinically significant change (depending on outcome measure) was shown between 1 in 2 and 1 in 10 patients. Improvements in physical function were lower with rates of 1 in 4 to 1 in 14 reporting significant gains. CONCLUSION: The effectiveness of the Ulysses CBT-PMP is established with measures of clinically significant change for physical and psychological outcomes contributing to the evidence for this novel approach of analysis. Future research determining benchmarks for CBT-PMP outcomes will assist clinicians in monitoring and enhancing patient's progress in clinical practice.

Outcomes of a group education/exercise intervention in a population of patients with non-specific low back pain: a 3-year review.

BACKGROUND: Low back pain (LBP) can prove resistant to treatment. Conservative management in form of education and exercise is advocated as a first-line treatment option. The format of exercise programmes varies, as does the scale of improvement. Individual and group models of care are commonly utilised. AIMS: To determine the effectiveness of a group education/exercise intervention in a cohort of patients with LBP in a teaching hospital in the south east of Ireland. In addition, the study explores which factors are predictive of a positive outcome. METHODS: Patients aged 18-65 years with LBP > 6 months, who completed the programme between January 2008 and December 2010 were included. Outcome measures were coded, entered into PASW 18 and cleaned. Pre and post scores were analysed with paired t tests and χ (2) analysis. Multiple regression modelling was used to determine which baseline variables were independent predictors of positive outcome. RESULTS: In total, 668 patients completed the programme. The mean age of patients was 45.9 ± 11.3 years and the majority of patients (69 %) were female. Three months post programme, significant improvements in all self report and objective physical measures were demonstrated (p < 0.001). Factors associated with a positive outcome included lower levels of baseline disability and distress, less baseline functional impairment, shorter duration of symptoms and not being involved in litigation. CONCLUSION: This group-based education/exercise programme proved effective in terms of decreasing pain, improving physical function and improving psychosocial status. Identifying factors predictive of positive outcome may help maximise patient outcomes.

The role of clinical specialist physiotherapists in the management of low back pain in a spinal triage clinic.

BACKGROUND: Traditional care pathways for patients with low back pain (LBP) where general practitioners (GPs) refer to consultant specialists can lead to excessive waiting times for patients and questionable use of health care resources. The evaluation of more cost effective pathways is a priority. AIMS: The study aims to determine if clinical specialist physiotherapists can allocate patients into the three distinct diagnostic triage categories in line with international guidelines. A secondary aim is to examine the utility of baseline domains to inform clinical decision making. METHODS: A review of LBP patients (n = 1,532) consecutively referred between 2008 and 2010 to a physiotherapy led spinal triage clinic was undertaken. Baseline demographics, pain severity (Visual Analogue Scale), disability (Roland Morris Disability Questionnaire), distress (Distress and Risk Assessment Method), mobility and function were assessed. Relationships between these factors were analysed. RESULTS: Eighty-five percent of the population were deemed suitable for conservative management and were referred for either group exercise intervention (n = 1,125, 73 %) or individual treatment (n = 178, 12 %), in line with clinical guidelines. Fourteen percent were discharged and only 1 % required a specialist opinion. Patients allocated to the three management streams could be clearly discriminated by baseline measures of pain, distress, disability and function (p < 0.01). CONCLUSION: Clinical Specialist physiotherapists are effective in assessing and selecting appropriate care pathways for LBP patients in line with international LBP clinical guidelines. The utility of the physical and psychological measures to differentiate between groups of varying clinical severity has important implications for treatment selection and management.

The impact of spinal cord stimulation on physical function and sleep quality in individuals with failed back surgery syndrome: a systematic review.

The aim of this review was to determine the impact of spinal cord stimulation (SCS) on physical function and sleep quality in individuals with failed back surgery syndrome (FBSS). This review comprised three phases: an electronic database search (PubMed, Cinahl Plus, EMBASE, PsychInfo, Pedro, Cochrane Library) identified potential papers; these were screened for inclusion criteria, with extraction of data from accepted papers and rating of internal validity by two independent reviewers using the Effective Public Health Practice Project quality assessment tool, a tool designed to assess non-RCTs (randomized controlled trials) as well as RCTs. Strength of the evidence was rated using the Agency for Health Care Policy and Research guidelines. The search generated 13 quantitative papers that fulfilled the inclusion criteria; all 13 studies investigated the impact of SCS on physical function, and nine studies investigated the impact of SCS on sleep quality. Consistent evidence (level C) found that SCS positively affected physical function, with improvements in participation in activities of daily living, leisure, social and work-related activities. Similarly, consistent evidence (level C) found improvements in sleep quality following SCS. Improvements in sleep quantity, a reduction in awakenings and a decrease in sleep medication use were also noted (level D). The impact of SCS on cognitive function, i.e., memory and concentration, was also assessed using the same search strategy, no papers fulfilled the inclusion criteria for this study. Spinal cord stimulation effectively addressed many physical function and sleep problems associated with FBSS; however, there is a need for further high-quality objective investigations to support this.

Peripheral neuropathy masquerading as an epidural complication.

BACKGROUND: Epidural anaesthesia generally provides safe postoperative pain control, but does carry a small risk of nerve damage. CASE DESCRIPTION: A 30-year-old woman with long standing rheumatoid arthritis underwent a primary total knee replacement under general anaesthetic. Postoperatively, a continuous epidural infusion was used for pain relief. On discontinuation of the epidural, she was confirmed to have a foot drop. Her subsequent investigation and management for neuropathic pain was coordinated by the acute pain service. Magnetic resonance imaging excluded a central lesion. Nerve conduction studies 6 weeks later confirmed peripheral nerve lesions. The patient's neurological deficit was not due to her epidural, but rather her intraoperative tourniquet. DISCUSSION: The episode raises a number of discussion points for our pain service around the use of epidurals for knee replacement surgery, the management of nerve injury and the ease at which the epidural can be blamed for coincident injuries. International evidence would suggest that neurological complications following knee replacement are more likely to be related to surgery can epidural analgesia.

Prevention of spinal anaesthesia-induced hypotension in the elderly: i.m. methoxamine or combined hetastarch and crystalloid.

We have compared two methods of reducing hypotension during spinal anaesthesia in elderly patients, 6% hetastarch and crystalloid or methoxamine 10 mg i.m., in terms of haemodynamic stability and requirements for additional vasopressors. Sixty-two patients (aged 60-97 yr) undergoing surgical fixation of fractured neck of femur were allocated randomly to receive 6% hetastarch (Hespan) 500 ml followed by Hartmann's solution 500 ml (group HS, n = 32) or a bolus injection of methoxamine 10 mg i.m. (group MX, n = 30), 10 min before induction of spinal anaesthesia with 0.5% hyperbaric bupivacaine 2.25-3.0 ml. Arterial pressure was measured non-invasively by an oscillotonometer at 2-min intervals from 0 to 40 min and at 5-min intervals thereafter. Methoxamine 2 mg i.v. was given if systolic arterial pressure (SAP) decreased to < 100 mm Hg. Hypotension was defined as a 25% decrease from baseline SAP or mean arterial pressure (MAP). Patient data, sensory level and blood loss were similar in the two groups. SAP and MAP increased initially from baseline until induction of spinal anaesthesia and then decreased for 30 min in both groups, but remained higher in group MX (P < 0.05). Heart rate (HR) decreased from baseline in group MX (P < 0.05) and was less than in group HS at all times from 2 to 60 min (P < 0.01). The incidence of SAP hypotension (47% vs 75%; P = 0.03, odds ratio (OR) = 3.43) and MAP hypotension (47% vs 67%; P = 0.09, OR = 2.51) was less in group MX than in group HS. Requirements for rescue methoxamine i.v. (27% vs 53%, P = 0.04, OR = 3.11) was less in group MX than in group HS but the dose of rescue methoxamine given (mean 6.3 (95% confidence intervals 3.0-9.6) vs 8.9 (5.6-12.2) mg) and time to onset of hypotension (20.7 (14.5-26.7) vs 17.3 (11.4-23.1) min) were similar in groups MX and HS, respectively. We conclude that methoxamine 10 mg i.m., given 10 min before induction of spinal anaesthesia in normovolaemic elderly patients, reduced subsequent SAP and MAP hypotension, HR and requirements for rescue vasopressor therapy compared with a combination of 6% hetastarch 500 ml and crystalloid 500 ml. The previously reported benefit of such volume administration may not extend to the elderly.

Acute superior vena caval syndrome with airway obstruction following elective mediastinoscopy.

A 47-year-old female patient had a subclinical superior vena caval syndrome which developed into the 'full blown' acute condition when she was placed into the left lateral position after mediastinoscopy. She developed airway obstruction requiring urgent re-intubation and subsequent admission to the intensive care unit. This subclinical condition might have been suspected pre-operatively if closer attention had been paid to the history, physical examination and review of the computerised axial tomography scan: she had a history of intermittent dysponea, wheeze and cough which was worse on waking and improved as the day progressed, she had a positive Pemberton's sign and the computerised axial tomography scan showed that the lesion was encroaching on the superior vena cava.

T-cell and macrophage subsets in the bronchial wall of clinically healthy subjects.

This study was conducted to obtain quantitative data on the numbers of T-cells and macrophage subsets in the normal bronchial wall of man, and, thus, produce a baseline against which the numbers of these cells present in inflamed bronchi may be judged. Bronchial biopsies were obtained from 27 clinically healthy subjects attending hospital for elective orthopaedic operations. Eight of the subjects were smokers (median 3.5 pack-years), and eight were atopic as defined by skin prick test. Three to eight weeks after biopsy, subjects attended the lung function laboratory for spirometric testing and determination of provocative concentration of histamine producing a 20% fall in forced expiratory volume in one second (PC20FEV1). The bronchial biopsies were frozen and cryostat sections prepared. These sections were investigated with immunohistological techniques to reveal the presence and distribution of T-cell and macrophage subsets. Twenty six out of 27 subjects had spirometric values within the normal range, but a wide spectrum of bronchial reactivity was observed (PC20FEV1 range 2-36 mg histamine). Using monoclonal antibodies in immunohistological techniques, only small numbers of T-cells were seen, the majority being CD8+ cells in the epithelium. In the underlying tissue, CD4+ cells predominated (CD4/CD8 ratio, epithelium 1:9; underlying tissue 4:1). In both cases, approx. 50% of T-cells expressed the CD45Ro isotype. Small numbers of macrophages were observed in all samples. The majority of these cells expressed a "suppressor cell" phenotype (RFD1+RFD7+), whilst only a small proportion (median 11% ) exhibited the phenotype of antigen presenting cells (RFD1+RFD7-).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparative evaluation of propofol and midazolam as sedative agents in fiberoptic bronchoscopy.

Propofol, a new intravenous sedative agent, was investigated in 41 asthmatic patients undergoing day-case (outpatient) fiberoptic bronchoscopy. The study design was a randomized comparison between propofol and midazolam, which is a well-established intravenous sedative agent. The age, weight, and American Society of Anesthesiologists physical status and lung function of the two groups were not significantly different. Mean (SD) induction dose of propofol was 104.7 (30.1) mg with a maintenance dose of 121.9 (38.5) mg. Corresponding values of midazolam were 9.3 (3.1) mg and 3.7 (2.3) mg. The required level of sedation was achieved significantly faster with propofol, mean (SD) 125.4 (39.8) s, compared with midazolam, 179.4 (55.2) s (p < 0.001). Significantly faster recovery was noted with propofol compared with midazolam in terms of time to recall name and date of birth 2.3 (1.7) min vs 6.3 (8.6) min, (p < 0.045). Alertness scored with the digital symbol substitution test (DSST) returned to prebronchoscopy values in the propofol group at 30 min, DSST score = 35.9 (18.2) vs 13.4 (9.1), in the midazolam group (p < .0001) and was still significantly higher at 90 min-39.4 (17.9) and 23.1 (13.8) (p < 0.01). We conclude that propofol is a useful sedating agent in fiberoptic bronchoscopy with similar efficacy to midazolam but with a faster onset of action and a more rapid recovery. These represent significant advantages for day-case procedures.

Lung function and immunopathological changes after inhaled corticosteroid therapy in asthma.

Six patients with asthma (American Thoracic Society (ATS) criteria), maintained on inhaled beta 2-agonists alone, were treated with inhaled corticosteroid (budesonide 400 micrograms b.d.) for a period of three months. Prior to steroid therapy, baseline spirometry, bronchodilator response and bronchial hyperresponsiveness were documented and endobronchial biopsies were obtained for immunopathological analysis. Frozen sections of the biopsies were investigated using immunoperoxidase methods, with a panel of monoclonal antibodies selected to reveal the presence and distribution of lymphocyte and macrophage subsets and HLA-DR expression. After three months the studies were repeated. Studies before steroid therapy revealed a T-cell-dominated inflammation in the bronchial wall of all subjects. Baseline airway obstruction, median (range) forced expiratory volume in one second (FEV1) 78.5 (61-109)% of predicted, with a significant bronchodilator response 20.8 (14-33)% and bronchial hyperresponsiveness to histamine geometric mean (SD) PC20FEV1 0.69 (2.5) mg was documented. Steroid therapy caused a significant reduction in bronchial hyperresponsiveness to histamine, with an increase in geometric mean PC20FEV1 to 2.22 (3.2) mg post steroid (p less than 0.03). Concurrent with a reduction in bronchodilator response and an increase in spirometric variables (improved forced midexpiratory flow (FEF25-75) p less than 0.03), there were marked reductions observed in the overall numbers of T-lymphocytes (CD 2, 5, 8), the numbers of CD45RO+ T-cells, and the numbers of macrophages (RFD1+) with the phenotype of antigen presenting cells. In all six subjects, reductions in the quantitative expression of HLA-DR molecules were also seen.(ABSTRACT TRUNCATED AT 250 WORDS)