Catherine Niven

Analgesia through the looking-glass? A randomized controlled trial investigating the effect of viewing a 'virtual' limb upon phantom limb pain, sensation and movement.

The extent to which viewing a ‘virtual’ limb, the mirror image of an intact limb, modifies the experience of a phantom limb, was investigated in 80 lower limb amputees before, during and after repeated attempts to simultaneously move both intact and phantom legs. Subjects were randomly assigned to one of two conditions, a control condition in which they only viewed the movements of their intact limb and a mirror condition in which they additionally viewed the movements of a ‘virtual’ limb. Although the mirror condition elicited a significantly greater number of phantom limb movements than the control condition, it did not attenuate phantom limb pain and sensations any more than the control condition. The potential of a ‘virtual’ limb as a treatment for phantom limb pain was discussed in terms of its ability to halt and/or reverse the cortical re‐organisation of motor and somatosensory cortex following acquired limb loss.

Assessing the pain of people with cognitive impairment

This review presents evidence of the undertreatment of pain for people with cognitive impairment and explores reasons for this, emphasizing inadequate detection due to lack of suitable pain assessment protocols. Implications for practice and suggestions for further research are made. Copyright

A study of labour pain using the MCGILL pain questionnaire

The McGill Pain Questionnaire (MPQ) was used to assess the nature and intensity of labour pain in 29 women. Subjects completed the MPQ during the first stage of labour, and again 24-48 hours post-natally, when they recalled the pain of the first and second stages of their childbirth. Labour pain was found, on average, to be severe. However, it varied greatly between subjects. In particular, one psychological factor--previous experience of pain--was found to be strongly associated with perceived levels of labour pain. Subjects who reported that they had previously experienced significant levels of pain unrelated to childbirth had low or moderate levels of labour pain. Subjects who reported little experience of pain unrelated to childbirth, had high levels of pain.

Does perineal suturing make a difference? The SUNS trial

Objective To examine differences in outcome between primiparous women who do and who do not have suturing to first or second degree perineal lacerations sustained during spontaneous vaginal births after 37 weeks of gestation.

Effects of algorithm for diagnosis of active labour: cluster randomised trial.

Objective To compare the effectiveness of an algorithm for diagnosis of active labour in primiparous women with standard care in terms of maternal and neonatal outcomes. Design Cluster randomised trial. Setting Maternity units in Scotland with at least 800 annual births. Participants 4503 women giving birth for the first time, in 14 maternity units. Seven experimental clusters collected data from a baseline sample of 1029 women and a post-implementation sample of 896 women. The seven control clusters had a baseline sample of 1291 women and a post-implementation sample of 1287 women. Intervention Use of an algorithm by midwives to assist their diagnosis of active labour, compared with standard care. Main outcomes Primary outcome: use of oxytocin for augmentation of labour. Secondary outcomes: medical interventions in labour, admission management, and birth outcome. Results No significant difference was found between groups in percentage use of oxytocin for augmentation of labour (experimental minus control, difference=0.3, 95% confidence interval −9.2 to 9.8; P=0.9) or in the use of medical interventions in labour. Women in the algorithm group were more likely to be discharged from the labour suite after their first labour assessment (difference=−19.2, −29.9 to −8.6; P=0.002) and to have more pre-labour admissions (0.29, 0.04 to 0.55; P=0.03). Conclusions Use of an algorithm to assist midwives with the diagnosis of active labour in primiparous women did not result in a reduction in oxytocin use or in medical intervention in spontaneous labour. Significantly more women in the experimental group were discharged home after their first labour ward assessment. Trial registration Current Controlled Trials ISRCTN00522952.

Variation in Phantom Limb Pain: Results of a Diary Study

Amputees experience multiple, complex problems in addition to phantom limb pain. Although studies have yielded useful data on the relationship between phantom limb pain and other variables, this research generally has evaluated only one aspect of phantom limb pain and measured it at only one time point. The present study examined ongoing phantom limb pain and associated factors prospectively through the use of hourly pain diaries that are completed over a 7-day period. The sample comprised a subset of 89 lower limb amputees taking part in a longitudinal research study. Subjects had a mean age of 46.1 years. Forty-seven per cent were female, 53% male. Subjects completed a Pain/Coping Diary that measured phantom limb pain intensity, activity levels, medication use, and alcohol use on an hourly basis over a 7-day period. It also asked subjects to list the coping strategies used on the same hourly basis over a 7-day period. The diaries highlighted the following: Phantom limb pain appears to be episodic in nature and there is great variation in its intensity. Amputees use a limited repertoire of coping strategies to deal with episodes of phantom limb pain, and of those strategies that are used, few reduce the level of pain. This variability in phantom limb pain has important implications for those involved in the care of amputees as a report of phantom limb pain at a given point in time may not reflect the amputees overall pain experience.

Risk assessment and decision making about in-labour transfer from rural maternity care: a social judgment and signal detection analysis

BackgroundThe importance of respecting women’s wishes to give birth close to their local community is supported by policy in many developed countries. However, persistent concerns about the quality and safety of maternity care in rural communities have been expressed. Safe childbirth in rural communities depends on good risk assessment and decision making as to whether and when the transfer of a woman in labour to an obstetric led unit is required. This is a difficult decision. Wide variation in transfer rates between rural maternity units have been reported suggesting different decision making criteria may be involved; furthermore, rural midwives and family doctors report feeling isolated in making these decisions and that staff in urban centres do not understand the difficulties they face. In order to develop more evidence based decision making strategies greater understanding of the way in which maternity care providers currently make decisions is required. This study aimed to examine how midwives working in urban and rural settings and obstetricians make intrapartum transfer decisions, and describe sources of variation in decision making.MethodsThe study was conducted in three stages. 1. 20 midwives and four obstetricians described factors influencing transfer decisions. 2. Vignettes depicting an intrapartum scenario were developed based on stage one data. 3. Vignettes were presented to 122 midwives and 12 obstetricians who were asked to assess the level of risk in each case and decide whether to transfer or not. Social judgment analysis was used to identify the factors and factor weights used in assessment. Signal detection analysis was used to identify participants’ ability to distinguish high and low risk cases and personal decision thresholds.ResultsWhen reviewing the same case information in vignettes midwives in different settings and obstetricians made very similar risk assessments. Despite this, a wide range of transfer decisions were still made, suggesting that the main source of variation in decision making and transfer rates is not in the assessment but the personal decision thresholds of clinicians.ConclusionsCurrently health care practice focuses on supporting or improving decision making through skills training and clinical guidelines. However, these methods alone are unlikely to be effective in improving consistency of decision making.

Remembering an everyday pain: the role of knowledge and experience in the recall of the quality of dysmenorrhoea

Abstract The ability to describe the quality of a previous pain may be thought to be better if one had experienced that particular pain because information stored in episodic and/or semantic memory is available rather than if one had not and could only guess what the pain may be like on the basis of information stored in semantic memory. However research has shown that not only is the quality of labour pain poorly recalled by women who have given birth but also it is no better described by them than by women who have never given birth at all. In order to replicate this effect for an everyday pain, the ability to recall the quantity and the quality of dysmenorrhoea was measured in two groups of women. One group regularly experienced dysmenorrhoea, the other had never experienced it. Analysis of the pain intensity scores revealed that the ‘pain’ group reported significantly less pain 2 weeks later whereas the ‘no‐pain’ group did not significantly differ in their rating over time. Analysis of the MPQ Descriptors chosen by subjects using Cohens kappa resulted in ‘fair’ recall for both groups with no significant advantage for the ‘pain’ group. These results suggest that the episodic memory system plays a limited role in facilitating the recall of the quality of an often experienced pain. However the semantic memory system allows both previous pain sufferers and pain guessers to describe the core qualities of a pain to the same extent. Further research is required to explain why remembering the quality of a pain experience is not advantaged by episodic memory and what facilitates the transfer of a pain experience into semantic event memory.

Managing the risk of suicide in acute psychiatric inpatients: A clinical judgement analysis of staff predictions of imminent suicide risk

Background: Predicting suicide risk in psychiatric in-patients in order to inform risk management decisions is compromised by the poor predictive validity of the available models. Aims: This study explored the factors influencing judgements regarding suicide risk in psychiatrists and nurses working in acute psychiatric in-patient units in Scotland. Method: Clinical judgement analysis. Information used by 12 psychiatrists and 52 nurses to make judgements about suicide risk were analysed over 130 hypothetical cases. Correlations and linear regression analysis were used to examine judgement consistency and information use. Results: There was agreement between clinicians on the relative but not absolute degree of risk of each patient case. Consistency of judgments was low, particularly amongst nurses. All clinicians rated those with more previous suicide attempts, men, those with shorter admission times, and those who were less compliant and not improving clinically as at greater risk of suicide. Conclusions: Clinicians use cues that have been associated with suicide in traditional predictive models based on epidemiological studies and short term factors that may be particularly relevant to acute psychiatric settings. The inconsistencies observed can be interpreted to cast doubt on the validity of predictions of risk for imminent suicide and the role of such predictions in the assessment process. Declaration of interest: None.

The purple line as a measure of labourprogress: a longitudinal study

BackgroundVaginal examination (VE) and assessment of the cervix is currently considered to be the gold standard for assessment of labour progress. It is however inherently imprecise with studies indicating an overall accuracy for determining the diameter of the cervix at between 48-56%. Furthermore, VEs can be unpleasant, intrusive and embarrassing for women, and are associated with the risk of introducing infection. In light of increasing concern world wide about the use of routine interventions in labour it may be time to consider alternative, less intrusive means of assessing progress in labour. The presence of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. The study described in this paper aimed to assess in what percentage of women in labour a purple line was present, clear and measurable and to determine if any relationship existed between the length of the purple line and cervical dilatation and/or station of the fetal head.MethodsThis longitudinal study observed 144 women either in spontaneous labour (n = 112) or for induction of labour (n = 32) from admission through to final VE. Women were examined in the lateral position and midwives recorded the presence or absence of the line throughout labour immediately before each VE. Where present, the length of the line was measured using a disposable tape measure. Within subjects correlation, chi-squared test for independence, and independent samples t-test were used to analyse the data.ResultsThe purple line was seen at some point in labour for 109 women (76%). There was a medium positive correlation between length of the purple line and cervical dilatation (r = +0.36, n = 66, P = 0.0001) and station of the fetal head (r = +0.42, n = 56, P < 0.0001).ConclusionsThe purple line does exist and there is a medium positive correlation between its length and both cervical dilatation and station of the fetal head. Where the line is present, it may provide a useful guide for clinicians of labour progress along side other measures. Further research is required to assess whether measurement of the line is acceptable to women in labour and also clinicians.