Nicola Adams

Evidence-based clinical practice guidelines on management of pain in older people

Pain in older people is not only under-recognised, but is also under-treated. Many professional bodies have documented that pain in this rapidly growing population is poorly controlled [1–7]. This may be related to attitudes and beliefs held by older people, which in turn affects their reporting of pain [8] but also due to misconceptions and educational deficits by health professionals [9, 10]. Treatment when prescribed is often limited to basic medication seldom tailored to the individual [11–14]. There is also a general failure by professionals to consider alternative pain relief options [2]. No doubt more needs to done and national guidance on the management of pain in older people is long overdue. Older people are different; the bio-physiological changes that occur with ageing, the accumulation of co-morbidities and co-prescription of medication, frailty and psychosocial changes make older people rather unique when considering treatment modalities for pain control. The British Geriatric Society and British Pain Society have collaborated to produce the first UK guideline on the management of pain in older people. The recommendations follow an extensive systematic review of the available literature and will help health professionals consider the options available when managing pain in older patients. The guideline has been categorised into sections dealing with pharmacology, interventional therapies, psychological interventions, physical activity and assistive devices and complementary therapies. This article provides a summary of the recommendations. The full guideline is available in the supplement accompanying this issue of the journal.

A pragmatic community-based intervention of multimodal physiotherapy plus deep water running (DWR) for fibromyalgia syndrome: a pilot study

Evidence-based recommendations support the use of multimodal therapy and hydrotherapy for fibromyalgia syndrome; however, there is little standardisation of such programmes. The aim of the study was to assess the effectiveness of a pool-based exercise using deep water running (DWR) as part of a multimodal physiotherapy programme for patients with fibromyalgia syndrome. For a non-randomised clinical study, 44 patients diagnosed with fibromyalgia were recruited from primary care. Patients in the experimental group received a multimodal programme incorporating pool-based exercise using DWR three times a week for an 8-week period. The control group received a leaflet containing advice and continued with normal activities. Patients were evaluated for physical function (Fibromyalgia Impact Questionnaire, FIQ), pain, general health (Short Form-12 Health Survey) and quality of life (European Quality of Life Scale-5D) pre- and post intervention. Statistically significant results were found for the experimental group for FIQ total score, incorporating physical function, pain, fatigue, stiffness and psychological variables (p < 0.05). Statistically significant differences between the experimental group and control were also found for general health (p < 0.05) and quality of life (p < 0.05). The results of this pilot study and the high level of compliance and adherence and low level of attrition suggest that this multimodal programme incorporating DWR is a safe and effective intervention for fibromyalgia syndrome that is acceptable to patients.

The use of proprioceptive neuromuscular facilitation in physiotherapy practice

Abstract Aims: The aim of this paper is to critically review the evidence base for the use of proprioceptive neuromuscular facilitation (PNF) in physiotherapy practice. Given the evolving understanding of underlying physiological concepts and research developments in the more than 50 years since Herman Kabat originated the concept, there is a need to review the current evidence base. Method: Empirical studies investigating the effectiveness of PNF for increasing range of movement and functional rehabilitation for clinical and non-clinical populations along with patterns and irradiation concepts were reviewed. Results: Although it was difficult to draw definitive conclusions due to the lack of cognate studies and varying methodological quality of papers, a number of studies did demonstrate encouraging results for the use of PNF, particularly with regard to increasing range of movement. Conclusions: Further research is needed to explore individual components of PNF therapeutic approaches and their wider application in key clinical populations such as stroke with standardized outcome measures appropriate to clinical practice. Secondly there is need for the development of new paradigms to fully consider the underlying physiological concepts explaining the effectiveness of PNF.

Psychological Models of Chronic Pain and Implications for Practice

Summary This brief review article presents the major psychological models of chronic pain, namely the psychodynamic/personality, behavioural, cognitive, cognitive-behavioural and psychophysiological models. Treatment approaches based upon these models are described and their usefulness, limitations and implications for physiotherapy practice are discussed. Since no model has proved to be superior over the others, and given the individuality of patients, it is suggested that the most effective way to apply these models would be to combine the appropriate components of each according to the unique needs of individual patients rather than to follow one particular model to the exclusion of the others.

Investigation of Personality Characteristics in Chronic Low Back Pain Patients Attending Physiotherapy Out-patient Departments

Summary Twenty-three chronic low back pain patients attending physiotherapy out-patient departments, who fulfilled pre-set criteria, completed a psychological questionnaire derived from the Minnesota Multiphasic Personality Inventory to test for depression, hypochondriasis, hysteria and psychasthenia. These results were compared with results obtained for a matched non-pain group. Using a non-parametric Mann-Whitney U test, significantly elevated scores were found for all scales in the patient group as compared with the non-patient group (p

Review of Personality Characteristics in Chronic Back Pain Patients

Summary In this review paper, to which there is a subsequent research report, the reader is introduced to personality characteristics that have been implicated in chronic low back pain patients. The characteristics of depression, hypochondriasis, hysteria and psychasthenia are presented. The interaction of psychological and physiological factors involved in the production and experience of pain is discussed. The paper then leads to the purpose of the subsequent study and the implications for practice.

A randomised controlled feasibility study investigating the use of eccentric and concentric strengthening exercises in the treatment of rotator cuff tendinopathy.

Objectives: To conduct a feasibility study to compare concentric and eccentric rotator cuff strengthening exercises for rotator cuff tendinopathy. Methods: A total of 11 patients with rotator cuff tendinopathy who were on the waiting list for arthroscopic subacromial decompression surgery were randomised to perform eccentric rotator cuff strengthening exercises, concentric strengthening exercises or no exercises. Patients were evaluated in terms of levels of pain and function using the Oxford Shoulder Score and a Visual Analogue Scale initially, at 4 weeks and at 8 weeks. Results: The study design was found to be acceptable to patients and achieved a high level of 86% compliance. The drop-out rate was 0%. Two patients performing eccentric strengthening exercises improved sufficiently to cancel their planned surgery. Conclusion: Further research in this area is recommended. The study design was feasible and power calculations have been conducted to aid future research planning.

Evidence-based clinical practice guidelines on the management of pain in older people: executive summary.

The British Pain Society and British Geriatric Society have collaborated to produce comprehensive pain management guidelines based on an extensive systematic review of the available literature by a professional multidisciplinary group. This guidance reviews the epidemiology and management of pain in older people with the aim of providing best practice recommendations for the management of pain by all health professionals working with older adults in any care setting and emphasises the importance of a multimodal approach in the management of pain in older people. Assessment of pain in older people has not been covered within this guidance but can be found in a separate document (http://britishpainsociety.org/book_pain_older_people.pdf).

A qualitative exploration of the views and experiences of women with Pregnancy related Pelvic Girdle Pain

OBJECTIVES To explore the views and experiences of women with Pregnancy related Pelvic Girdle Pain (PPGP), and to inform the design and development of a subsequent feasibility study. DESIGN Using a philosophical stance of pragmatism, one-to-one audio recorded semi-structured interviews were used. All interviews were conducted once by a male interviewer, and analysed using an interpretive thematic data analytic approach through five steps: transcription, precoding, coding, categorisation and theme generation, with reflexivity adopted throughout the data synthesis process. SETTING A Womens Health Physiotherapy Department in the North East of England between April 2014 to June 2014. PARTICIPANTS Eight pregnant women suffering with Pregnancy related Pelvic Girdle Pain. MAIN OUTCOME MEASURES Womens experiences of Pregnancy related Pelvic Girdle Pain. RESULTS Three themes emerged: Reality of Pregnancy related Pelvic Girdle Pain; Key Mechanisms of Support and; Impact of Knowledge. Participants reported biopsychosocial symptoms, which included pain, reduced activities of daily living, psychological distress and social isolation. Participants valued the support of a healthcare professional through face to face contact and the interventions that they provided, as well as information on the condition. CONCLUSIONS Whilst there were some limitations to this study, the biopsychosocial symptoms discussed here justify the investigation of acupuncture for Pregnancy related Pelvic Girdle Pain. The design and development of a subsequent feasibility study, specifically in areas of recruitment, acceptability of the intervention and appropriate selection of outcome measures were informed by this study.

Korean hand acupuncture for pregnancy related pelvic girdle pain: a feasibility study

This thesis aimed to assess the feasibility of conducting a randomised controlled trial (RCT) into the use of Korean Hand Acupuncture (KHA) for pregnancy related pelvic girdle pain (PPGP). Despite PPGP developing in approximately 20% of all pregnant women, there are currently very few studies that have investigated interventional strategies, with a dearth of UK based studies. Of extant interventions investigated to date, acupuncture has shown some promising findings, although the effects of KHA on PPGP remain unclear. In line with the MRC framework for complex interventions, any potential treatment should be subjected to feasibility testing prior to a definitive RCT. This three phase feasibility study followed a mixed methods paradigm. Phase 1 was a comparative study of 20 non pregnant women, measuring the belief that there had been a needle inserted into the skin, between a penetrating KHA (pKHA) group and a non-penetrating KHA (npKHA) group. Between group analysis found that at initial assessment (p=0.07) and one week post intervention (p=0.643), believability was similar. Qualitative comments were analysed through content analysis, and provided insight into what factors influenced their belief score, such as ‘acupuncture noises’. The study findings helped to develop the intervention protocol in Phase 3. This study was the first to investigate the believability of a non penetrating form of KHA. Phase 2 recruited eight PPGP sufferers and adopted a qualitative approach, using semistructured interviews to gain an understanding of how PPGP affected them. Data was subjected to thematic analysis and produced four themes: The reality of PPGP; Support mechanisms most important in PPGP; Vulnerability and; Knowledge is power. Findings indicated PPGP is a problem that is biopsychosocial, and one which is represented via the Pelvic Girdle Questionnaire (PGQ). It demonstrated that information provision was considered as important to the participants within this study as it is to sufferers outside of the UK, and that they valued health care professional advice and support. This is the first UK based study to investigate women’s experience of PPGP, the first piece of qualitative work with the lead author and interviewer being male, the first to provide a level of validity to PGQ use within the UK and the first to adopt a pragmatic philosophy. Phase 3 was a mixed methods feasibility study, assessing the acceptability and practicality of conducting a definitive RCT on KHA for PPGP. A two armed study consisting of six sessions in either a standard physiotherapy plus pKHA or a standard physiotherapy plus npKHA group. The study recruited 59 women, 40 of whom completed all six sessions. Acceptability and practicality was confirmed through content analysis of the qualitative data produced by the participants, in particular those in the pKHA group who stated they would seek out the treatment again. Further acceptability was noted as all adverse events experienced were minor and transient, and that the retention of women to the study was greater than normally expected from the study population. In addition, trends noted in NRS at present (p=0.002) and PGQ (p=0.041) at the final data point indicated that pKHA may have additional benefits over npKHA for PPGP. The original contributions from Phase 3 are that it is the first study to be conducted using KHA for a pregnancy related condition in the English language and the first study to adopt a mixed methods approach within the UK for an acupuncture study within pregnancy. Finally, it is the first study written in English that has compared pKHA to npKHA for any condition.