Lorraine De Souza

Early intervention for the management of acute low back pain: A single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise

Study Design. A single blind randomized controlled trial comparing two models of care for patients with acute simple low back pain. Objectives. To compare two research-based models of care for acute low back pain and investigate the effect of the timing of physical intervention. Summary of Background Data. National guidelines offer conflicting information on the delivery of physical treatment in the management of acute low back pain. The guidelines suggest two different models of care. Direct comparisons between these models are lacking in the literature. The present study aims to compare these approaches to the management of acute low back pain. Methods. Among 804 referred patients, 102 subjects met the specific admission criteria and were randomly assigned to an “assess/advise/treat” group or an “assess/advise/wait” group. The intervention consisted of biopsychosocial education, manual therapy, and exercise. Assessment of short-term outcome enables comparison to be made between intervention and advice to stay active. Assessment of long-term outcome enables comparison to be made between early and late intervention. Study outcomes of reported pain (Visual Analogue Scale), functional disability (the Roland and Morris Disability Questionnaire), mood (Modified Zung Self Rated Depression Score, Modified Somatic Perception Questionnaire, State-Trait Anxiety Inventory), general health (Euroqol), and quality of life (Short Form 36) were assessed at baseline, 6 weeks, 3 months, and 6 months. Results. At 6 weeks, the assess/advise/treat group demonstrated greater improvements in disability, mood, general health, and quality of life than patients in the assess/advise/wait group (P < 0.05). Disability and pain were not significantly different between the groups at long-term follow up (P > 0.05). However, mood, general health, and quality of life remained significantly better in the assess/advise/treat group (P < 0.05). Conclusions. At short-term, intervention is more effective than advice on staying active, leading to more rapid improvement in function, mood, quality of life, and general health. The timing of intervention affects the development of psychosocial features. If treatment is provided later, the same psychosocial benefits are not achieved. Therefore, an assess/advise/treat model of care seems to offer better outcomes than an assess/advise/wait model of care.

Young people's experiences using electric powered indoor – outdoor wheelchairs (EPIOCs): Potential for enhancing users' development?

Purpose. To examine the experiences of severely physically disabled young people who use electric powered indoor – outdoor chairs (EPIOCs). Methods. A priori interview questions examined young peoples functioning with EPIOCs, pain and discomfort with EPIOC use and accidents or injuries resulting from EPIOC use. Eighteen young people (13 males and five females) aged 10 – 18 (mean 15) years were interviewed by telephone using a qualitative framework approach. Participants were interviewed 10 – 19 (mean 14.5) months after delivery of the chair. Diagnoses included muscular dystrophy (n = 10), cerebral palsy (n = 5), and ‘other’ (n = 3). Results. Many children reported positive functioning following EPIOC use, including increased independence and social activities like wheelchair football. However, EPIOC use was also associated with pain and discomfort, as well as perceived lack of safety, and minor accidents. Most young people and their families were fairly satisfied with the service and provision of their wheelchairs. Conclusions. The findings suggest that the development of disabled young people may benefit from the use of electric powered indoor/outdoor wheelchairs, although the advantages may come at certain costs to young peoples perceived and real safety. Recommendations to powered wheelchair providers include the demonstrated need for additional driving training as these young people mature.

Evaluation of the effectiveness of professionally guided self-care for people with multiple sclerosis living in the community: A randomized controlled trial

Objective: The aim of the study was to assess the ef”cacy of a patient-focused professionally guided self-care programme for the management of multiple sclerosis (MS) in the community. Design: This was a single-blind randomized controlled trial. Setting: The study was conducted with people with MS living in the community. Participants: Two hundred and seventy-eight people with MS were invited to take part in the study. One hundred and eighty-nine people consented to take part (68%). Of these 183 began the study and 169 (92.3%) completed it. Seventy-three individuals were in the intervention group and 96 were in the control group. Intervention: The intervention comprised discussion of self-care based on client priorities, using an information booklet about self-care. Main outcome measures: These included the Barthel Index, a measure of mobility, the SF-36, and the Standard Day Dependency Record (SDDR) which measures the need for assistance with daily activities. Assessments were conducted at baseline and again six months later. Results: Changes in health status were small. However, at follow-up the intervention group had better SF-36 health scores, in mental health (p = 0.04), and vitality (p = 0.05) and considered help with daily activities to be less essential, as measured by the SDDR (p = 0.04), than the control group. Participants in the intervention group had maintained levels of independence at follow-up (p = 0.62) while the control group showed a signi”cant decrease in independence (p = 0.001). Conclusion: This intervention could be a useful aid for health professionals who are supporting people with MS living in the community.

Patients' experiences of the impact of chronic back pain on family life and work.

Purpose. The emotional distress caused by pain is one of the most disruptive aspects of living with the condition. This study investigates how individuals experience pain and its consequences for family life and work. Method. Unstructured interviews, using the ‘Framework’ approach with topic guide, were recorded and transcribed. Patients were sampled for age, sex, ethnicity and occupation from new referrals with spinal pain (SP) to a rheumatology outpatient clinic. Eleven patients (five males and six females) were interviewed in English (n = 9) or their preferred language (n = 2). Interviews were read in depth twice to identify the topics. Data were extracted in phrases and sentences using thematic content analysis. Results. Emergent themes reported were relationships with: spouses and partners (n = 7), children/parents (n = 6), with other family and friends (n = 7) and work-related issues (n = 11). Patients valued support from family but expressed concerns about causing them worry. Work-related issues included physical and emotional efforts to keep working when in pain, fear of losing employment and financial problems. Conclusion. Patients expressed anxiety about how their pain affected other family members, regret at losing full work capacity and worry about financial consequences. The lived experience of chronic SP has ramifications that go beyond the individual, reaching into work and social relationships.Purpose. The emotional distress caused by pain is one of the most disruptive aspects of living with the condition. This study investigates how individuals experience pain and its consequences for family life and work.Method. Unstructured interviews, using the ‘Framework’ approach with topic guide, were recorded and transcribed. Patients were sampled for age, sex, ethnicity and occupation from new referrals with spinal pain (SP) to a rheumatology outpatient clinic. Eleven patients (five males and six females) were interviewed in English (n = 9) or their preferred language (n = 2). Interviews were read in depth twice to identify the topics. Data were extracted in phrases and sentences using thematic content analysis.Results. Emergent themes reported were relationships with: spouses and partners (n = 7), children/parents (n = 6), with other family and friends (n = 7) and work-related issues (n = 11). Patients valued support from family but expressed concerns about causing them worry. Work-related issues incl...

Transcranial direct current stimulation of the motor cortex in the treatment of chronic nonspecific low back pain: a randomized, double-blind exploratory study.

Objectives:To test the proof of principle that active anodal transcranial direct current stimulation (tDCS) applied to the motor cortex reduces pain significantly more than sham stimulation in a group of participants with chronic nonspecific low back pain. Methods:The study utilized a within-participants sham-controlled, interrupted time series design. A sample of 8 participants was recruited. After 3 days of baseline measures, patients entered a 15-day experimental period (Mondays to Fridays) for 3 consecutive weeks. During this period each patient received sham stimulation daily until a randomly allocated day when active stimulation was commenced. Active stimulation was then given daily for the remaining days of the experimental period. Both the participants and the assessors were blinded. The primary outcomes were average pain intensity and unpleasantness in the last 24 hours measured using a visual analogue scale. Secondary outcomes included self-reported disability, depression and anxiety, a battery of cognitive tests to monitor for unwanted effects of stimulation, and patients’ perceptions of whether they had received active or sham stimulation. Data were analyzed using generalized estimating equations. Results:No significant effect was seen in the primary outcomes between active and sham stimulation (average pain intensity P=0.821, unpleasantness P=0.937) or across any other clinical variables. There was evidence that patients may have been able to distinguish between the active and sham conditions (P=0.035). Discussion:These results do not provide evidence that tDCS is effective in the treatment of chronic back pain. The use of a small convenience sample limits the generalizability of these findings and precludes definitive conclusions on the efficacy of tDCS in chronic nonspecific low back pain.

Electric-powered indoor/outdoor wheelchairs (EPIOCs): users' views of influence on family, friends and carers

Purpose. This study explored the effects of electric-powered indoor/outdoor wheelchair (EPIOC) provision to users on their family and carers. Method. EPIOC users receiving their chairs between February and November 2002 (N = 74) were invited to participate in a telephone questionnaire/interview, and 64 agreed. This study examined the responses to the question ‘Has the use of your EPIOC affected your family or friends in any way?’ and related comments. Interviews were analysed using a qualitative framework approach to identify emergent themes. In addition, the proportion of individuals raising issues related to each theme was determined. Participants were interviewed 10–19 (mean = 14.3) months after chair delivery. Results. The following themes emerged: reduced physical burden on family/friends and increased independence and freedom. However, an EPIOC does not eliminate other practical problems particularly during transportation and negotiating kerbs and slopes. Users also reported anxiety/worry in relationship to EPIOC use, e.g., weather conditions, personal safety (muggings), use of ramps and kerbs. Conclusion. There are considerable benefits to families and carers associated with powered wheelchair use. A reduction in the physical demand for pushing and increased freedom were identified. These benefits appear to outweigh the residual practical difficulties and worries.

Do Numerical Rating Scales and the Roland-Morris Disability Questionnaire capture changes that are meaningful to patients with persistent back pain?:

Objectives: To investigate patients’ views about two common outcome measures used for back pain: Numerical Rating Scales for pain and the Roland-Morris Disability Questionnaire. Subjects: Thirty-six working adults who had previously sought primary care for back pain and who could speak and read English. Method: Eight focus groups were conducted to explore participants’ views about the 11-point Numerical Rating Scales and the 24-item Roland-Morris Disability Questionnaire. Each group was led by a facilitator and an interview topic guide was used. Audio recordings of focus groups were transcribed verbatim. Framework analysis was used to chart participants’ views and an interpretive analysis performed to explain the findings. Results: Participants reported that neither the Roland-Morris nor the Numerical Rating Scales captured the complex personal experience of pain or relevant changes in their condition. The time-frame of assessment was identified as particularly problematic and the Roland-Morris did not capture relevant functional domains. Conclusion: This study provides empirical data that working adults with persistent back pain consider these clinical outcome measures largely inadequate. These measures currently used for back pain may contribute to misleading conclusions about treatment efficacy and patient recovery.

A Delphi study of self-care in a community population of people with multiple sclerosis

Objective: The aim of the study was to obtain the views and priorities of people with multiple sclerosis (MS) to inform the design of a professionally guided self-care programme. Design: A three-round postal Delphi survey was used as a research tool. Setting: The study was conducted at the Centre for Research in Rehabilitation at Brunel University in London. Subjects: The respondent panel consisted of 200 volunteers with MS of whom 136 responded to the survey (68%). Respondents were recruited through voluntary organizations throughout the UK. The only selection criterion was that the diagnosis of MS was confirmed by the general practitioner. Main outcome measures: The results from each of the three rounds of the Delphi survey were the outcome measures. Results: One hundred and one people used ten or more self-care strategies (74%). Round 1 data revealed the diversity of practices reported, crossing many domains of life such as daily chores, leisure, relationships and physical and mental health. The top five priorities identified in rounds 2 and 3 concerned coping strategies, social support, independence in daily living, rest and mobility. Complete consensus about priorities was not achieved. However, agreement about priorities approached stability across rounds 2 and 3 and a highly significant Kendalls coefficient of concordance indicated there was good agreement within round 3 group rankings (W = 0.46, chi-squared = 499.37, df = 9, p<0.001, N = 122). Conclusion: Self-care practices were widespread, and those most commonly used could be identified. This survey method allows the views and priorities of this consumer group to be revealed. The information obtained can be used to develop services where the professional guides and encourages appropriate self-management based upon the issues that people with MS consider to be most important.

Dealing With Chronic Pain: Giving Voice to the Experiences of Mothers With Chronic Pain and Their Children

Despite the substantial monetary, personal, and social cost of chronic pain, research into the family life of sufferers is wanting. Parents dealing with chronic pain, as well as their children, have been particularly neglected. Using qualitative interview data from 16 mothers suffering from a variety of chronic pain conditions, and their 21 children, aged 6 to 12 years, we explored the impact of maternal chronic pain on mothers and children. Consistent with a gains-and-loss theory and the strengths perspective, the findings revealed both positive and challenging aspects of pain. Despite the presence of risks—including maternal stress, parenting difficulties, and childrens distress—maternal chronic pain also provided opportunities for growth in many families. The findings suggest that maternal chronic pain can catalyze enhanced development as well as adversity. Researchers and clinicians should be aware of the pitfalls facing families dealing with chronic pain, while remaining open to the possibility that some families might flourish.

Using interpretative phenomenological analysis to inform physiotherapy practice: An introduction with reference to the lived experience of cerebellar ataxia

Qualitative research methods that focus on the lived experience of people with health conditions are relatively underutilised in physiotherapy research. This article aims to introduce interpretative phenomenological analysis (IPA), a research methodology oriented toward exploring and understanding the experience of a particular phenomenon (e.g., living with spinal cord injury or chronic pain, or being the carer of someone with a particular health condition). Researchers using IPA try to find out how people make sense of their experiences and the meanings they attach to them. The findings from IPA research are highly nuanced and offer a fine grained understanding that can be used to contextualise existing quantitative research, to inform understanding of novel or underresearched topics or, in their own right, to provoke a reappraisal of what is considered known about a specified phenomenon. We advocate IPA as a useful and accessible approach to qualitative research that can be used in the clinical setting to inform physiotherapy practice and the development of services from the perspective of individuals with particular health conditions.