Novel and effective treatment modality for medically unexplained symptoms

Medically unexplained symptoms (MUS) confound physicians, and the incidence and prevalence of these conditions is poorly documented.  This is not least due to the complex nature of MUS and mimicry of morbidity with conditions that have common clinical assessment and treatment modalities, e.g. migraine headaches which stress headaches commonly are misdiagnosed as.  Effective treatment modalities for MUS have been more or less non-existent.  In the following we present a modality for the assessment, diagnosis and treatment of MUS that in our experience leads to cure, at least in better than half of these cases measured in terms of allowing the individual back to work.  These results are at least twice as high as those described hitherto (see below), and yet, our treatment modality is beset with many obstacles, not the least of which is the intrasigence of a system that will not and/or can not understand why this modality is so much better than what they are able to offer.  The most importance obstacle is financing, as this modality requires long term and committed financing to work.  The economic implications of not dealing with these issues are described.

Outcome after traumatic injury

The thesis' aim was to explore outcome after traumatic injury. Poorer physical health prior to injury and receipt of compensation explained variance in physical health 12 months after injury. Poorer mental health 3 and 12 months after injury was partly explained by stronger emotional reactions immediately after the injury, receipt of compensation, and lower perceived social support. The portfolio focuses on symptoms of depression and anxiety in those suffering chronic pain. Through four case studies who attended a pain management service, it is argued that psychological symptoms are able to be addressed concurrently with pain management strategies.

The importance of understanding motives for prescription substance use and misuse in sport

The use and misuse of prescription substances in the broader community, and among athletes in particular, is receiving increased attention, and one Australian sporting code is introducing testing for some of these substances. While testing in sport occurs in part to protect the health of the athlete, our responses to positive notifications are often punitive. Given that some prescription substances, such as opioids, are used to treat pain, and use has among athletes has been linked to pain sustained during sporting competition, understanding the prevalence and motivations of use among this group is important. Equally so is how the sporting community responds to this growing issue.

The experience of anxiety in colonoscopy outpatients: a mixed-method study.

Colonoscopy is commonly used to investigate gastrointestinal symptoms such as pain or changes in bowel habits and may either induce patient anxiety or assist in patient reassurance. Currently, 2 studies investigating negative colonoscopy, reassurance, and anxiety came to conflicting conclusions on this issue. Furthermore, it is possible that differences in coping styles may influence patient anxiety. A mixed-methods study was conducted with 26 precolonoscopy and 24 postcolonoscopy patients to address the conflicting, limited literature regarding colonoscopy, coping, and anxiety. Participants completed postal surveys and interviews were conducted with 16 participants. There was no significant difference between pre- and postcolonoscopy groups on any anxiety measures; however, this was possibly because of individual differences. Significant positive correlations were found between maladaptive coping and state anxiety indicating that healthcare professionals should consider screening for maladaptive coping in patients needing invasive procedures. Neither problem- nor emotion-focused coping showed any significant relationship with state anxiety. Interviews revealed that clinicians and endoscopy nurses should be aware that some patients are not absorbing correct information about colonoscopy, specifically that they may be conscious or experience pain during the procedure. Because of this, clinicians should ensure that patients understand standard practice at their hospital. In addition, interview data suggested that more attention should be given to pain management as it currently may not be adequate during conscious sedation.

Blood-nourishing and hard-softening capsule costs less in the management of osteoarthriticknee pain : A randomized controlled trial

The blood-nourishing and hard-softening (BNHS) capsule is a traditional Chinese formula used in the symptomatic treatment of inflammation and pain. We conducted this randomized controlled trial to compare the efficacy of BNHS with other commonly prescribed drugs. We recruited 120 patients from two teaching hospitals; 30 patients in each hospital were randomly assigned to receive BNHS. In one hospital, the 30 controls were given another traditional Chinese drug; whereas a Western medicine (chondroprotection drug/Viartril-s) was used as the control in the other hospital. Intervention was carried out over a period of 4 weeks. Primary outcome measures included self-reported pain level, and changes in stiffness and functional ability as measured by the Western Ontario McMaster Universities Osteoarthritis (WOMAC) index. Mixed models were used for statistical analysis. Substantial improvements in disease-specific symptoms were observed, after 4 weeks of treatment, in patients taking BNHS capsules. As assessed by the WOMAC index, pain level of the BNHS group decreased by 57% [95% confidence interval (CI) = 50, 63], stiffness by 63% (95% CI = 55, 71) and functional ability increased by 56% (95% CI = 50, 63). No significant differences were found in any of the outcome measures between the BNHS group and either of the comparison groups. No severe adverse effects were reported. However, this study lacked a placebo group; therefore, we conclude that BNHS appears to be as effective as commonly prescribed medicines for the relief of pain and dysfunction in knee osteoarthritis patients, but costs a lot less than other Western and herbal drugs in the study.

Optimal stimulation duration of tens in the management of osteoarthritic knee pain

Objective: This study examined the optimal stimulation duration of transcutaneous electrical nerve stimulation (TENS) for relieving osteoarthritic knee pain and the duration (as measured by half-life) of post-stimulation analgesia. Subjects: Thirty-eight patients received either: (i) 20 minutes (TENS20); (ii) 40 minutes (TENS40); (iii) 60 minutes (TENS60) of TENS; or (iv) 60 minutes of placebo TENS (TENSPL) 5 days a week for 2 weeks. Methods: A visual analogue scale recorded the magnitude and pain relief period for up to 10 hours after stimulation. Results: By Day10, a significantly greater cumulative reduction in the visual analogue scale scores was found in the TENS40 (83.40%) and TENS60 (68.37%) groups than in the TENS20 (54.59%) and TENSPL (6.14%) groups (p 3 0.000), such a group difference was maintained in the 2-week followup session (p 3 0.000). In terms of the duration of post-stimulation analgesia period, the duration for the TENS40 (256 minutes) and TENS60 (258 minutes) groups was more prolonged than in the other 2 groups (TENS20 = 168 minutes, TENSPL = 35 minutes) by Day10 (p 3 0.000). However, the TENS40 group produced the longest pain relief period by the follow-up session. Conclusion: 40 minutes is the optimal treatment duration of TENS, in terms of both the magnitude (VAS scores) of pain reduction and the duration of post-stimulation analgesia for knee osetoarthritis.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: protocol of a systematic review and meta-synthesis of qualitative studies.

INTRODUCTION: Low back pain is the highest ranked condition contributing to years lived with disability, and is a significant economic and societal burden. Evidence-based clinical practice guidelines are designed to improve quality of care and reduce practice variation by providing graded recommendations based on the best available evidence. Studies of low back pain guideline implementation have shown no or modest effects at changing clinical practice. OBJECTIVES: To identify enablers and barriers to adherence to clinical practice guidelines for the management of low back pain. METHODS AND ANALYSIS: A systematic review and meta-synthesis of qualitative studies that will be conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. Eight databases will be searched using a priori inclusion/exclusion criteria. Two independent reviewers will conduct a structured review and meta-synthesis, and a third reviewer will arbitrate where there is disagreement. This protocol has been registered on PROSPERO 2014. ETHICS AND DISSEMINATION: Ethical approval is not required. The systematic review will be published in a peer-reviewed journal. The review will also be disseminated electronically, in print and at conferences. Updates of the review will be conducted to inform and guide healthcare translation into practice. TRIAL REGISTRATION NUMBER: PROSPERO 2014:CRD42014012961. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014012961.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: a systematic review and meta-synthesis of qualitative studies

INTRODUCTION: Despite the availability of evidence-based guidelines for the management of low back pain that contain consistent messages, large evidence-practice gaps in primary care remain.

OBJECTIVES: To perform a systematic review and meta-synthesis of qualitative studies that have explored primary care clinicians' perceptions and beliefs about guidelines for low back pain, including perceived enablers and barriers to guideline adherence.

METHODS: Studies investigatingperceptions and beliefs about low back pain guidelines were included if participants were primary care clinicians and qualitative methods had been used for both data collection and analysis. We searched major databases up to July 2014. Pairs of reviewers independently screened titles and abstracts, extracted data, appraised method quality using the CASP checklist, conducted thematic analysis and synthesized the results in narrative format.

RESULTS: Seventeen studies, with a total of 705 participants, were included. We identified three key emergent themes and eight subthemes: (1) guideline implementation and adherence beliefs and perceptions; (2) maintaining the patient-clinician relationship with imaging referrals; (3) barriers to guideline implementation. Clinicians believed that guidelines were categorical, prescriptive and constrained professional practice; however popular clinical practices superseded the guidelines. Imaging referrals were used to manage consultations and to obtain definitive diagnoses. Clinicians' perceptions reflected a lack of content knowledge and understanding of how guidelines are developed.

DISCUSSION: Addressing misconceptions and other barriers to uptake of evidence-based guidelines for managing low back pain is needed to improve knowledge transfer and close the evidence-practice gap in the treatment of this common condition.

Population based intervention to change back pain beliefs and disability : three part evaluation

Objective To evaluate the effectiveness of a population based, state-wide public health intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and costs of compensation. Design Quasi-experimental, non-randomised, non-equivalent, before and after telephone surveys of the general population and postal surveys of general practitioners with an adjacent state as control group and descriptive analysis of claims database. Setting Two states in Australia Participants 4730 members of general population before and two and two and a half years after campaign started, in a ratio of2:1:1; 2556 general practitioners before and two years after campaign onset. Main outcome measures Back beliefs questionnaire, knowledge and attitude statements about back pain, incidence of workers' financial compensation claims for back problems, rate of days compensated, and medical payments for claims related to back pain and other claims. Results In the intervention state beliefs about back pain became more positive between successive surveys (mean improvement in questionnaire score 1.9 (95% confidence interval 1.3 to 2.5), P<0.001 and 3.2 (2.6 to 3.9), P < 0.001, between baseline and the second and third survey, respectively). Beliefs about back pain also improved among doctors. There was a clear decline in number of claims for back pain, rates of days compensated, and medical payments for claims for back pain over the duration of the campaign. Conclusions A population based strategy of provision of positive messages about back pain improves population and general practitioner beliefs about back pain and seems to influence medical management and reduce disability and workers' compensation costs related to back pain.

Wildlife management in Australasia : perceptions of objectives and priorities

The aim of this study was to examine the values and attitudes held by Australasian wildlife managers as they relate to wildlife management issues, and to gain some insight into possible future directions and priorities for Australasian wildlife management. During December 2002 – February 2003, 138 questionnaires were completed by members of the Australasian Wildlife Management Society (AWMS) and registrants of the 2002 AWMS annual conference. Threatened species management, threatened communities/habitats, and management of introduced species were the issues rated as needing the highest priority for the Australasian Wildlife Management Society. Issues such as animal rights, genetically modified organisms and timber harvesting on public lands were the lowest-rating issues. Respondents expressed a strong belief in managing and controlling wildlife to achieve wildlife management objectives, a strong belief that wildlife should be protected and that wildlife managers should minimise the pain and suffering of individual animals, and a belief that resources should be directed towards conserving wildlife populations rather than protecting individual animals from non-threatened populations. While respondents held a strong belief that it is important to consult the community when developing wildlife management policies and programs, there was little support for a comanagerial approach where the community has a significant role to play in decision-making processes.

A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy

Objectives: This non-randomised pilot study investigated the effect of eccentric quadriceps training on 17 patients (22 tendons) with painful chronic patellar tendinopathy.

Methods: Two different eccentric exercise regimens were used by subjects with a long duration of pain with activity (more than six months). (a) Nine consecutive patients (10 tendons; eight men, one woman; mean age 22 years) performed eccentric exercise with the ankle joint in a standard (foot flat) position. (b) Eight patients (12 tendons; five men, three women; mean age 28 years) performed eccentric training standing on a 25° decline board, designed to increase load on the knee extensor mechanism. The eccentric training was performed twice daily, with three sets of 15 repetitions, for 12 weeks. Primary outcome measures were (a) 100 mm visual analogue scale (VAS), where the subject recorded the amount of pain during activity, and (b) return to previous activity. Follow up was at 12 weeks, with a further limited follow up at 15 months.

Results: Good clinical results were obtained in the group who trained on the decline board, with six patients (nine tendons) returning to sport and showing a significantly reduced amount of pain over the 12 week period. Mean VAS scores fell from 74.2 to 28.5 (p = 0.004). At 15 months, four patients (five tendons) reported satisfactory results (mean VAS 26.2). In the standard squat group the results were poor, with only one athlete returning to previous activity. Mean VAS scores in this group were 79.0 at baseline and 72.3 at 12 weeks (p = 0.144).

Conclusion: In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced encouraging results in terms of pain reduction and return to function in the short term. Eccentric exercise using standard single leg squats in a similar sized group appeared to be a less effective form of rehabilitation in reducing pain and returning subjects to previous levels of activity.

Diabetes management in patients receiving palliative care

A literature review revealed no evidence-based guidelines specific to managing diabetes in the context of palliative care. The purpose of the current project was to describe the management practices of doctors and nurses caring for people with diabetes and advanced disease. Palliative care doctors, palliative care nurses, endocrinologists, and diabetes nurse educators participated in this study. A two-phase project was undertaken: 1) two focus groups, and 2) a cross-sectional survey using a self-completed questionnaire. The focus group and questionnaire data identified that doctors and nurses used a range of practices and blood glucose testing frequencies to control blood glucose based on experience and not according to a robust evidence base. Implications for practice include the importance of collaboration between diabetes and palliative care specialists, and the need to develop clinical management guidelines.

Wildlife management in Australasia : perceptions of objectives and priorities

The aim of this study was to examine the values and attitudes held by Australasian wildlife managers as they relate to wildlife management issues, and to gain some insight into possible future directions and priorities for Australasian wildlife management. During December 2002 – February 2003, 138 questionnaires were completed by members of the Australasian Wildlife Management Society (AWMS) and registrants of the 2002 AWMS annual conference. Threatened species management, threatened communities/habitats, and management of introduced species were the issues rated as needing the highest priority for the Australasian Wildlife Management Society. Issues such as animal rights, genetically modified organisms and timber harvesting on public lands were the lowest-rating issues. Respondents expressed a strong belief in managing and controlling wildlife to achieve wildlife management objectives, a strong belief that wildlife should be protected and that wildlife managers should minimise the pain and suffering of individual animals, and a belief that resources should be directed towards conserving wildlife populations rather than protecting individual animals from non-threatened populations. While respondents held a strong belief that it is important to consult the community when developing wildlife management policies and programs, there was little support for a comanagerial approach where the community has a significant role to play in decision-making processes.