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Southern C, Tutton E, Dainty KN, Seers K, Pearson NA, Couper K, Ellard DR, Perkins GD, Haywood KL. The experiences of cardiac arrest survivors and their key supporters following cardiac arrest: A systematic review and meta-ethnography. Resuscitation 2024; 198:110188. [PMID: 38548009 DOI: 10.1016/j.resuscitation.2024.110188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/18/2024] [Indexed: 04/09/2024]
Abstract
AIM To review qualitative studies on the experience of sudden cardiac arrest survival from the perspective of both survivors and their key supporters, including family/close friends. METHODS A seven-step meta-ethnography and synthesis of qualitative evidence was undertaken, informed by the Meta-Ethnography Reporting Guidelines (eMERGe). Four major databases were searched (Medline, EMBASE, CINAHL, PsycINFO; January 1995-January 2022, updated July 2023) for qualitative studies exploring survivors' and/or key supporters' experiences of cardiac arrest survival. The Critical Appraisal Skills Programme checklist and Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual) were applied to evaluate the overall confidence in research findings. Constructs were identified from each paper, informing theme and sub-theme development. RESULTS From 15,917 unique titles/abstracts and 196 full-text articles, 32 met the inclusion criteria. Three themes captured the survivors' experiences: 1) Making sense of my cardiac arrest; 2) Learning to trust my body and mind; and 3) Re-evaluating my life. A further three themes reflected key supporters' experiences: 1) Emotional turmoil; 2) Becoming a carer: same person but different me; and 3) Engaging with a new and unknown world. However, limited data and some methodological weaknesses in included studies reduced confidence in several themes. The findings were conceived within the overarching concept of 'negotiating a new normal'. CONCLUSIONS The enduring psychosocial and physical sequelae of cardiac arrest survival substantially impacts the lives of survivors and their key supporters, requiring negotiation of their 'new normality'. The need for sense-making, physical and psychological recovery, and the new roles for key supporters should be strong considerations in the development of future interventions.
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Affiliation(s)
- Charlotte Southern
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, England
| | - Elizabeth Tutton
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, England; Kadoorie, Oxford Trauma Research and Emergency Care, NDORMS, Oxford University, UK; Major Trauma Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford UK
| | - Katie N Dainty
- Office of Research & Innovation, North York General Hospital, Toronto Ontario Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Kate Seers
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, England
| | - Nathan A Pearson
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, England
| | - Keith Couper
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, England; Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, England; University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Gavin D Perkins
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kirstie L Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, England.
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Kearney RS, Ellard DR, Parsons H, Haque A, Mason J, Nwankwo H, Bradley H, Drew S, Modi C, Bush H, Torgerson D, Underwood M. Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial. BMJ 2024; 384:e076925. [PMID: 38233068 PMCID: PMC10792684 DOI: 10.1136/bmj-2023-076925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To assess the effects of an additional programme of physiotherapy in adults with a first-time traumatic shoulder dislocation compared with single session of advice, supporting materials, and option to self-refer to physiotherapy. DESIGN Pragmatic, multicentre, randomised controlled trial (ARTISAN). SETTING AND PARTICIPANTS Trauma research teams at 41 UK NHS Trust sites screened adults with a first time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively. People were excluded if they presented with both shoulders dislocated, had a neurovascular complication, or were considered for surgical management. INTERVENTIONS One session of advice, supporting materials, and option to self-refer to physiotherapy (n=240) was assessed against the same advice and supporting materials and an additional programme of physiotherapy (n=242). Analyses were on an intention-to-treat basis with secondary per protocol analyses. MAIN OUTCOME MEASURES The primary outcome was the Oxford shoulder instability score (a single composite measure of shoulder function), measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L, and complications. RESULTS 482 participants were recruited from 40 sites in the UK. 354 (73%) participants completed the primary outcome score (n=180 allocated to advice only, n=174 allocated to advice and physiotherapy). Participants were mostly male (66%), with a mean age of 45 years. No significant difference was noted between advice compared with advice and a programme of physiotherapy at six months for the primary intention-to-treat adjusted analysis (between group difference favouring physiotherapy 1.5 (95% confidence interval -0.3 to 3.5)) or at earlier three month and six week timepoints. Complication profiles were similar across the two groups (P>0.05). CONCLUSIONS An additional programme of current physiotherapy is not superior to advice, supporting materials, and the option to self-refer to physiotherapy. TRIAL REGISTRATION Current Controlled Trials ISRCTN63184243.
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Affiliation(s)
| | - David R Ellard
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Helen Parsons
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Aminul Haque
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - James Mason
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Henry Nwankwo
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Helen Bradley
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Stephen Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chetan Modi
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Howard Bush
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
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Konda NN, Lewis TL, Furness HN, Miller GW, Metcalfe AJ, Ellard DR. Surgeon views regarding the adoption of a novel surgical innovation into clinical practice: systematic review. BJS Open 2024; 8:zrad141. [PMID: 38266120 PMCID: PMC10807848 DOI: 10.1093/bjsopen/zrad141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/22/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND The haphazard adoption of new surgical technologies into practice has the potential to cause patient harm and there are many misconceptions in the decision-making behind the adoption of new innovations. The aim of this study was to synthesize factors affecting a surgeon's decision to adopt a novel surgical innovation into clinical practice. METHODS A systematic literature search was performed to obtain all studies where surgeon views on the adoption of a novel surgical innovation into clinical practice have been collected. The databases screened were MEDLINE, Embase, Science Direct, Scopus, the Web of Science, and the Cochrane Library of Systematic Reviews (last accessed October 2022). Innovations covered multiple specialties, including cardiac, general, urology, and orthopaedics. The quality of the papers was assessed using a 10-question Critical Appraisal Skills Programme (CASP) tool for qualitative research. RESULTS A total of 26 studies (including 1112 participants, of which 694 were surgeons) from nine countries satisfied the inclusion and exclusion criteria. Types of study included semi-structured interviews and focus groups, for example. Themes and sub-themes that emerged after a thematic synthesis were categorized using five causal factors (structural, organizational, patient-level, provider-level, and innovation-based). These themes were further split into facilitators and barriers. Key facilitators to adoption of an innovation include improved clinical outcomes, cost-effectiveness, and support from internal and external stakeholders. Barriers to adoption include lack of organizational support and views of senior surgeons. CONCLUSION There are multiple complex factors that dynamically interact, affecting the adoption of a novel surgical innovation into clinical practice. There is a need to further investigate surgeon and other stakeholder views regarding the strength of clinical evidence required to support the widespread adoption of a surgical innovation into clinical practice.
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Affiliation(s)
- Nagarjun N Konda
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry, UK
- Department of Trauma and Orthopaedic Surgery, University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Thomas L Lewis
- Department of Trauma and Orthopaedic Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Hugh N Furness
- Department of Trauma and Orthopaedic Surgery, Imperial College London, London, UK
| | - George W Miller
- Department of Trauma and Orthopaedic Surgery, Bart’s and the London NHS Foundation Trust, London, UK
| | - Andrew J Metcalfe
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry, UK
- Department of Trauma and Orthopaedic Surgery, University Hospitals Coventry & Warwickshire, Coventry, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry, UK
- Department of Trauma and Orthopaedic Surgery, University Hospitals Coventry & Warwickshire, Coventry, UK
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Griffin J, Davis ET, Parsons H, Stevens S, Bradley H, Bruce J, Ellard DR, Haddad F, Hutchinson CE, Mason J, Nwankwo H, Metcalfe A, Smith T, Smith J, Warwick J, Skinner JA, Rees S, Underwood M, Khatri C, Wall PDH. UK robotic arthroplasty clinical and cost effectiveness randomised controlled trial for hips (RACER-Hip): a study protocol. BMJ Open 2023; 13:e079328. [PMID: 37852762 PMCID: PMC10603453 DOI: 10.1136/bmjopen-2023-079328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 10/20/2023] Open
Abstract
INTRODUCTION The number of robotic-assisted hip replacement procedures has expanded globally with the intended aim of improving outcomes. Intraoperative robotic-arm systems add additional costs to total hip replacement (THR) surgery but may improve surgical precision and could contribute to diminished pain and improved function. Additionally, these systems may reduce the need for expensive revision surgery. Surgery with conventional instruments may be just as successful, quick and affordable. There is timely demand for a robust evaluation of this technology. METHODS AND ANALYSIS The Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial for Hips (RACER-Hip) is a multicentre (minimum of six UK sites), participant-assessor blinded, randomised controlled trial. 378 participants with hip osteoarthritis requiring THR will be randomised (1:1) to receive robotic-assisted THR, or THR using conventional surgical instruments. The primary outcome is the Forgotten Joint Score at 12 months post-randomisation; a patient-reported outcome measure assessing participants' awareness of their joint when undertaking daily activities. Secondary outcomes will be collected post-operatively (pain, blood loss and opioid usage) and at 3, 6, 12, 24 months, then 5 and 10 years postrandomisation (including function, pain, health-related quality of life, reoperations and satisfaction). Allocation concealment will be accomplished using a computer-based randomisation procedure on the day of surgery. Blinding methods include the use of sham incisions for marker clusters and blinded operation notes. The primary analysis will adhere to the intention-to-treat principle. Results will adhere to Consolidated Standards of Reporting Trials statements. ETHICS AND DISSEMINATION The trial was approved by an ethics committee (Solihull Research Ethics Committee, 30 June 2021, IRAS: 295831). Participants will provide informed consent before agreeing to participate. Results will be disseminated using peer-reviewed journal publications, presentations at international conferences and through the use of social media. We will develop plans to disseminate to patients and public with our patient partners. TRIAL REGISTRATION NUMBER ISRCTN13374625.
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Affiliation(s)
- James Griffin
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Edward T Davis
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Helen Parsons
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Siobhan Stevens
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Bradley
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Fares Haddad
- Department of Orthopaedics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Charles E Hutchinson
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Henry Nwankwo
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Toby Smith
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Jane Warwick
- Warwick Medical School, University of Warwick, Coventry, UK
- Patient Representative, Coventry, UK
| | - John A Skinner
- Limb Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, UK
| | - Sophie Rees
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chetan Khatri
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Winsper C, Bhattacharya R, Bhui K, Currie G, Edge D, Ellard DR, Franklin D, Gill PS, Gilbert S, Miller R, Motala Z, Pinfold V, Sandhu H, Singh SP, Weich S, Giacco D. Improving mental healthcare access and experience for people from minority ethnic groups: an England-wide multisite experience-based codesign (EBCD) study. BMJ Ment Health 2023; 26:e300709. [PMID: 37463794 PMCID: PMC10357761 DOI: 10.1136/bmjment-2023-300709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/27/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Long-standing ethnic inequalities in access and mental healthcare were worsened by the COVID-19 pandemic. OBJECTIVES Stakeholders coproduced local and national implementation plans to improve mental healthcare for people from minority ethnic groups. METHODS Experience-based codesign conducted in four areas covered by National Health Service (NHS) mental health trusts: Coventry and Warwickshire, Greater Manchester, East London and Sheffield. Data were analysed using an interpretivist-constructivist approach, seeking validation from participants on their priority actions and implementation plans. Service users (n=29), carers (n=9) and health professionals (n=33) took part in interviews; focus groups (service users, n=15; carers, n=8; health professionals, n=24); and codesign workshops (service users, n=15; carers, n=5; health professionals, n=21) from July 2021 to July 2022. FINDINGS Each study site identified 2-3 local priority actions. Three were consistent across areas: (1) reaching out to communities and collaborating with third sector organisations; (2) diversifying the mental healthcare offer to provide culturally appropriate therapeutic approaches and (3) enabling open discussions about ethnicity, culture and racism. National priority actions included: (1) co-ordination of a national hub to bring about system level change and (2) recognition of the centrality of service users and communities in the design and provision of services. CONCLUSIONS Stakeholder-led implementation plans highlight that substantial change is needed to increase equity in mental healthcare in England. CLINICAL IMPLICATIONS Working with people with lived experience in leadership roles, and collaborations between NHS and community organisations will be essential. Future research avenues include comparison of the benefits of culturally specific versus generic therapeutic interventions.
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Affiliation(s)
- Catherine Winsper
- Research and Innovation, Caludon Centre, Coventry and Warwickshire Partnership Trust, Clifford Bridge Road, Coventry, UK
| | - Rahul Bhattacharya
- Tower Hamlets Home Treatment Team, East London NHS Foundation Trust, Robert Dolan House, Trust Headquarters, 9 Alie Street, London, UK
| | - Kamaldeep Bhui
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Graeme Currie
- Warwick Business School, University of Warwick, Coventry, UK
| | - Dawn Edge
- Division of Psychology & Mental Health, G6 Coupland 1 Building, The University of Manchester, Manchester, UK
| | - David R Ellard
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Donna Franklin
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Paramjit S Gill
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Steve Gilbert
- Steve Gilbert Consulting, Suite 2A, Blackthorn House, St Pauls Square, Birmingham, UK
| | - Robin Miller
- School of Social Policy, University of Birmingham, Birmingham, UK
| | - Zahra Motala
- Department of Sociology, University of Manchester, Manchester, UK
| | | | - Harbinder Sandhu
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Swaran P Singh
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Scott Weich
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Domenico Giacco
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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6
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Griffin J, Davis ET, Parsons H, Gemperle Mannion E, Khatri C, Ellard DR, Blyth MJ, Clement ND, Deehan D, Flynn N, Fox J, Grant NJ, Haddad FS, Hutchinson CE, Mason J, Mohindru B, Scott CEH, Smith TO, Skinner JA, Toms AD, Rees S, Underwood M, Metcalfe A. Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial (RACER-knee): a study protocol. BMJ Open 2023; 13:e068255. [PMID: 37295832 PMCID: PMC10277111 DOI: 10.1136/bmjopen-2022-068255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION Robotic-assisted knee replacement systems have been introduced to healthcare services worldwide in an effort to improve clinical outcomes for people, although high-quality evidence that they are clinically, or cost-effective remains sparse. Robotic-arm systems may improve surgical accuracy and could contribute to reduced pain, improved function and lower overall cost of total knee replacement (TKR) surgery. However, TKR with conventional instruments may be just as effective and may be quicker and cheaper. There is a need for a robust evaluation of this technology, including cost-effectiveness analyses using both within-trial and modelling approaches. This trial will compare robotic-assisted against conventional TKR to provide high-quality evidence on whether robotic-assisted knee replacement is beneficial to patients and cost-effective for healthcare systems. METHODS AND ANALYSIS The Robotic Arthroplasty Clinical and cost Effectiveness Randomised controlled trial-Knee is a multicentre, participant-assessor blinded, randomised controlled trial to evaluate the clinical and cost-effectiveness of robotic-assisted TKR compared with TKR using conventional instruments. A total of 332 participants will be randomised (1:1) to provide 90% power for a 12-point difference in the primary outcome measure; the Forgotten Joint Score at 12 months postrandomisation. Allocation concealment will be achieved using computer-based randomisation performed on the day of surgery and methods for blinding will include sham incisions for marker clusters and blinded operation notes. The primary analysis will adhere to the intention-to-treat principle. Results will be reported in line with the Consolidated Standards of Reporting Trials statement. A parallel study will collect data on the learning effects associated with robotic-arm systems. ETHICS AND DISSEMINATION The trial has been approved by an ethics committee for patient participation (East Midlands-Nottingham 2 Research Ethics Committee, 29 July 2020. NRES number: 20/EM/0159). All results from the study will be disseminated using peer-reviewed publications, presentations at international conferences, lay summaries and social media as appropriate. TRIAL REGISTRATION NUMBER ISRCTN27624068.
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Affiliation(s)
- James Griffin
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Edward T Davis
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Helen Parsons
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Elke Gemperle Mannion
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chetan Khatri
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mark J Blyth
- Orthopaedic Research Unit, Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - Nicholas David Clement
- Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - David Deehan
- Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | | | | | | | - Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Charles E Hutchinson
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Bishal Mohindru
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chloe E H Scott
- Department of Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Toby O Smith
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - John A Skinner
- Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
| | - Andrew D Toms
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Sophie Rees
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Ellard DR, Nichols VP, Griffiths FE, Underwood M, Taylor SJC. Chronic Headache Education and Self-Management Study (CHESS): a process evaluation. BMC Neurol 2023; 23:8. [PMID: 36609224 PMCID: PMC9823254 DOI: 10.1186/s12883-022-02792-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/05/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The Chronic Headache Education and Self-Management Study (CHESS) multicentre randomised trial evaluated the impact a group education and self-management support intervention with a best usual care plus relaxation control for people living with chronic headache disorders (tension type headaches or chronic migraine, with or without medication overuse headache). Here we report the process evaluation exploring potential explanations for the lack of positive effects from the CHESS intervention. METHODS The CHESS trial included 736 (380 intervention: 356 control) people across the Midlands and London UK. We used a mixed methods approach. Our extensive process evaluation looked at context, reach, recruitment, dose delivered, dose received, fidelity and experiences of participating in the trial, and included participants and trial staff. We also looked for evidence in our qualitative data to investigate whether the original causal assumptions underpinning the intervention were realised. RESULTS The CHESS trial reached out to a large diverse population and recruited a representative sample. Few people with chronic tension type headaches without migraine were identified and recruited. The expected 'dose'of the intervention was delivered to participants and intervention fidelity was high. Attendance ("dose received") fell below expectation, although 261/380 (69%) received at least at least the pre-identified minimum dose. Intervention participants generally enjoyed being in the groups but there was little evidence to support the causal assumptions underpinning the intervention were realised. CONCLUSIONS From a process evaluation perspective despite our extensive data collection and analysis, we do not have a clear understanding of why the trial outcome was negative as the intervention was delivered as planned. However, the lack of evidence that the intervention causal assumptions brought about the planned behaviour change may provide some insight. Our data suggests only modest changes in managing headache behaviours and some disparity in how participants engaged with components of the intervention within the timeframe of the study. Moving forwards, we need a better understanding of how those who live with chronic headache can be helped to manage this disabling condition more effectively over time. TRIAL REGISTRATION ISRCTN79708100 .
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Affiliation(s)
- David R. Ellard
- grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK ,grid.412570.50000 0004 0400 5079University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Vivien P. Nichols
- grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Frances E. Griffiths
- grid.7372.10000 0000 8809 1613Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Martin Underwood
- grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK ,grid.412570.50000 0004 0400 5079University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Stephanie J. C. Taylor
- grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AB UK
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Underwood M, Achana F, Carnes D, Eldridge S, Ellard DR, Griffiths F, Haywood K, Hee SW, Higgins H, Mistry D, Mistry H, Newton S, Nichols V, Norman C, Padfield E, Patel S, Petrou S, Pincus T, Potter R, Sandhu H, Stewart K, Taylor SJC, Matharu MS. A Supportive Self-Management Program for People With Chronic Headaches and Migraine: A Randomized Controlled Trial and Economic Evaluation. Neurology 2022; 100:e1339-e1352. [PMID: 36526428 PMCID: PMC10065208 DOI: 10.1212/wnl.0000000000201518] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/20/2022] [Indexed: 12/23/2022] Open
Abstract
Background and Objectives:Chronic headache disorders are a major cause of pain and disability. Education and supportive self-management approaches could reduce burden of headache disability. We tested the effectiveness of a group educational and supportive self-management programme for people living with chronic headaches.Methods:A pragmatic randomised controlled trial. Participants were aged ≥18 years with chronic migraine or chronic tension type headache, with or without medication overuse headache.We primarily recruited from general practices. Participants were assigned to either a two-day group education and self-management programme, a one-to-one nurse interview, and telephone support or to usual care plus relaxation material.The primary outcome was headache related quality of life using the Headache Impact Test (HIT-6) at 12 months. The primary analysis used intention-to-treat principles for participants with migraine and both baseline and 12-month HIT-6 data.Results:Between April 2017 and March 2019, we randomised 736 participants. Since only nine participants just had tension type headache our main analyses were on the 727 participants with migraine. Of these 376 were allocated to the self-management intervention 351 to usual care. Data from 586 (81%) participants were analysed for primary outcome. There was no between group difference in HIT-6, (adjusted mean difference = -0·3, 95% CI -1·23 to 0·67), or headache days (0·9, 95% CI -0·29, 2·05), at 12 months. The CHESS intervention generated incremental adjusted costs of £268 (95% CI,£176 to £377) [USD383 (95%CI USD252 to USD539)] and incremental adjusted quality-adjusted life years (QALYs) of 0.031 (95% CI -0.005 to .063). The incremental cost-effectiveness ratio was £8,617 (USD12,322) per QALY gained.Discussion:These findings conclusively show a lack of benefit for quality of life or monthly headache days from a brief group education and supportive self-management programme for people living with chronic migraine or chronic tension type headache with episodic migraine.Registered on the International Standard Randomized Controlled Trial Number registry,ISRCTN7970810016th December 2015https://doi.org/10.1186/ISRCTN79708100The first enrolment was 24th April 2017.Classification of evidence:This study provides Class III evidence that a brief group education and self-management program does not increase the probability of improvement in headache related quality of life in people with chronic migraine.
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Affiliation(s)
- Martin Underwood
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom.
| | - Felix Achana
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Dawn Carnes
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Sandra Eldridge
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - David R Ellard
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Frances Griffiths
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Kirstie Haywood
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Siew Wan Hee
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Helen Higgins
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Dipesh Mistry
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Hema Mistry
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Sian Newton
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Vivien Nichols
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Chloe Norman
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Emma Padfield
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Shilpa Patel
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Stavros Petrou
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Tamar Pincus
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Rachel Potter
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Harbinder Sandhu
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Kimberley Stewart
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Stephanie J C Taylor
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Manjit S Matharu
- From the Warwick Clinical Trials Unit (M.U., F.A., D.E., H.H., D.M., H.M., V.N., C.N., E.P., S.P., R.P., H.S., K.S.), and Division of Health Sciences (F.G., K.H., S.W.H.), Warwick Medical School University of Warwick, Coventry; University Hospitals Coventry and Warwickshire (M.U., D.E., H.M.), Coventry; University College of Osteopathy (D.C.), London; Wolfson Institute of Population Health (S.E., S.N., S.J.C.T.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Nuffield Department of Primary Care Health Sciences (S.P.), University of Oxford; Department of Psychology (T.P.), Royal Holloway University of London; and Headache Group Institute of Neurology (M.S.M.) and the National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
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Inman JGK, Ellard DR. What influences graduate medical students' beliefs of lower back pain? A mixed methods cross sectional study. BMC Med Educ 2022; 22:633. [PMID: 35987611 PMCID: PMC9392230 DOI: 10.1186/s12909-022-03692-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 08/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Low back pain (LBP) is a common condition with substantial associated disability and costs, best understood using a biopsychosocial approach. Research demonstrates that beliefs about LBP are important, with biomedical beliefs influencing practitioner's management and patient recovery. Beliefs about LBP can be inconsistent amongst healthcare and medical students. The aim of this study was to investigate graduate medical student's beliefs of LBP and what influences them. METHOD A cross sectional mixed methods study of Phase 1 (first year) and Phase 3 (third and fourth year) current graduate medical students at the University of Warwick (MBChB) was conducted. Participants were recruited via voluntary response sampling. A survey investigated LBP beliefs, utilising the Back Beliefs Questionnaire (BBQ) and Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS). Qualitative data was collected on what influences beliefs about the causes and management of LBP, which was analysed descriptively using thematic analysis. RESULTS Fifty-seven students completed the questionnaire (61% female), with a mean age of 27.2 years. Eighty two percent of participants reported a history of LBP. Median BBQ scores were 31.5 for phase 1 and 31 for phase 3, with median HC-PAIRS scores of 57 and 60 for phase 1 and phase 3 students respectively. Three main themes emerged from the qualitative data: Sources of influence, influence of personal experience and influence of medical education. Participants discussed single or multiple sources influencing their beliefs about the causes and management of LBP. Another main theme was the influence of experiencing LBP personally or through discussions with family, friends and patients. The final main theme described the influence of medical education, including lectures, seminars and clinical placements. CONCLUSIONS The HC-PAIRS and BBQ scores suggest graduate medical students in this sample tended to have positive beliefs about the outcome of LBP and functional expectations of chronic LBP patients, consistent with other healthcare students. The findings from qualitative data suggest how medical students form beliefs about the causes and management of LBP is complex.
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Affiliation(s)
- John G. K. Inman
- Warwick Medical School, Medical School Building, University of Warwick, Coventry, CV4 7HL UK
| | - David R. Ellard
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7HL UK
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10
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Tassinari CJ, Higham R, Smith IL, Arnold S, Mujica-Mota R, Metcalfe A, Simpson H, Murray D, McGonagle DG, Sharma H, Hamilton TW, Ellard DR, Fernandez C, Reynolds C, Harwood P, Croft J, Stocken DD, Pandit H. Clinical and cost-effectiveness of Knee Arthroplasty versus Joint Distraction for Osteoarthritis (KARDS): protocol for a multicentre, phase III, randomised control trial. BMJ Open 2022; 12:e062721. [PMID: 35772819 PMCID: PMC9247693 DOI: 10.1136/bmjopen-2022-062721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Knee replacement (KR) is a clinically proven procedure typically offered to patients with severe knee osteoarthritis (OA) to relieve pain and improve quality of life. However, artificial joints fail over time, requiring revision associated with higher mortality and inferior outcomes. With more young people presenting with knee OA and increasing life expectancy, there is an unmet need to postpone time to first KR. Knee joint distraction (KJD), the practice of using external fixators to open up knee joint space, is proposed as potentially effective to preserve the joint following initial studies in the Netherlands, however, has not been researched within an NHS setting. The KARDS trial will investigate whether KJD is non-inferior to KR in terms of patient-reported postoperative pain 12 months post-surgery. METHODS AND ANALYSIS KARDS is a phase III, multicentre, pragmatic, open-label, individually randomised controlled non-inferiority trial comparing KJD with KR in patients with severe knee OA, employing a hybrid-expertise design, with internal pilot phase and process evaluation. 344 participants will be randomised (1:1) to KJD or KR. The primary outcome measure is the Knee Injury and Osteoarthritis Outcomes Score (KOOS) pain domain score at 12 months post-operation. Secondary outcome measures include patient-reported overall KOOS, Pain Visual Analogue Scale and Oxford Knee Scores, knee function assessments, joint space width, complications and further interventions over 24 months post-operation. Per patient cost difference between KR and KJD and cost per quality-adjusted life year (QALY) gained over 24 months will be estimated within trial, and incremental cost per QALY gained over 20 years by KJD relative to KR predicted using decision analytic modelling. ETHICS AND DISSEMINATION Ethics approval was obtained from the Research Ethics Committee (REC) and Health Research Authority (HRA). Trial results will be disseminated at clinical conferences, through relevant patient groups and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN14879004; recruitment opened April 2021.
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Affiliation(s)
- Cerys Joyce Tassinari
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials, University of Leeds, Leeds, UK
| | - Ruchi Higham
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials, University of Leeds, Leeds, UK
| | - Isabelle Louise Smith
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials, University of Leeds, Leeds, UK
| | - Susanne Arnold
- Warwick Clinical Trials Unit, University of Warwick Warwick Medical School, Coventry, UK
| | | | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick Warwick Medical School, Coventry, UK
- Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Hamish Simpson
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - David Murray
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Dennis G McGonagle
- Chapel Allerton Hospital, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Hemant Sharma
- Department of Orthopaedics, Hull and East Yorkshire Hospitals NHS Trust, Hull, Kingston upon Hull, UK
| | - Thomas William Hamilton
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, University of Warwick Warwick Medical School, Coventry, UK
| | - Catherine Fernandez
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials, University of Leeds, Leeds, UK
| | - Catherine Reynolds
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials, University of Leeds, Leeds, UK
| | - Paul Harwood
- University of Leeds, Leeds Institute of Medical Research, Leeds, West Yorkshire, UK
| | - Julie Croft
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials, University of Leeds, Leeds, UK
| | - Deborah D Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials, University of Leeds, Leeds, UK
| | - Hemant Pandit
- Chapel Allerton Hospital, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, NIHR Leeds Biomedical Research Centre, Leeds, UK
- Chapel Allerton Hospital, Leeds, West Yorkshire, UK
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11
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Southern C, Tutton E, Seers K, Pearson NA, Couper K, Dainty KN, Ellard DR, Perkins GD, Haywood KL. OR03 ‘I can't do this alone’: A qualitative systematic review of significant others’ experiences’ following cardiac arrest survival. Resuscitation 2022. [DOI: 10.1016/s0300-9572(22)00385-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Nichols V, Pearce G, Ellard DR, Evans S, Haywood K, Norman C, Potter R, Sandhu H, Stewart K, Underwood M, Patel S. Patient and public involvement in a UK National Institute for Health Research Programme Grant for Applied Research: experiences from the Chronic Headache Education and Self-management Study (CHESS). Prim Health Care Res Dev 2021; 22:e72. [PMID: 34796815 PMCID: PMC8628557 DOI: 10.1017/s1463423621000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/02/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Patient and public involvement (PPI) plays a crucial role in ensuring research is carried out in conjunction with the people that it will impact upon. In this article, we present our experiences and reflections from working collaboratively with patients and public through the lifetime of an National Institute for Health Research (NIHR) programme grant; the Chronic Headache Education and Self-management Study (CHESS) which took place between 2015 and 2020. PPI OVER THE COURSE OF CHESS We worked closely with three leading UK migraine charities and a lay advisory group throughout the programme. We followed NIHR standards and used the Guidance for Reporting Involvement of Patients and the Public checklist. We consulted our PPI contacts using a variety of methods depending on the phase of the study and the nature of the request. This included emails, discussions, and face-to-face contact.PPI members contributed throughout the study in the programme development, in the grant application, ethics documentation, and trial oversight. During the feasibility study; in supporting the development of a classification interview for chronic headache by participating in a headache classification conference, assessing the relevance, and acceptability of patient-reported outcome measures by helping to analyse cognitive interview data, and testing the smartphone application making suggestions on how best to present the summary of data collected for participants. Due to PPI contribution, the content and duration of the study intervention were adapted and a Delphi study with consensus meeting developed a core outcome set for migraine studies. CONCLUSIONS The involvement of the public and patients in CHESS has allowed us to shape its overall design, intervention development, and establish a core outcome set for future migraine studies. We have reflected on many learning points for the future application of PPI.
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Affiliation(s)
- Vivien Nichols
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Gemma Pearce
- School of Psychological, Social and Behavioural Sciences, Coventry University, Coventry, CV1 5FB, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | | | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Chloe Norman
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Rachel Potter
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Harbinder Sandhu
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Kimberley Stewart
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
- University Hospitals of Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Shilpa Patel
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
- University Hospitals of Coventry and Warwickshire, Coventry, CV2 2DX, UK
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13
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Forster A, Airlie J, Ellwood A, Godfrey M, Green J, Cundill B, Dawkins B, McMaster N, Hulme C, Cicero R, McLellan V, Graham L, Gallagher B, Ellard DR, Firth J, Farrin A. An intervention to increase physical activity in care home residents: results of a cluster-randomised, controlled feasibility trial (the REACH trial). Age Ageing 2021; 50:2063-2078. [PMID: 34304268 PMCID: PMC8581372 DOI: 10.1093/ageing/afab130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Care home (CH) residents are mainly inactive, leading to increased dependency and low mood. Strategies to improve activity are required. DESIGN AND SETTING Cluster randomised controlled feasibility trial with embedded process and health economic evaluations. Twelve residential CHs in Yorkshire, United Kingdom, were randomised to the MoveMore intervention plus usual care (UC) (n = 5) or UC only (n = 7). PARTICIPANTS Permanent residents aged ≥65 years. INTERVENTION MoveMore: a whole home intervention involving all CH staff designed to encourage and support increase in movement of residents. OBJECTIVES AND MEASUREMENTS Feasibility objectives relating to recruitment, intervention delivery, data collection and follow-up and safety concerns informed the feasibility of progression to a definitive trial. Data collection at baseline, 3, 6 and 9 months included: participants' physical function and mobility, perceived health, mood, quality of life, cognitive impairment questionnaires; accelerometry; safety data; intervention implementation. RESULTS 300 residents were screened; 153 were registered (62 MoveMore; 91 UC). Average cluster size: MoveMore: 12.4 CHs; UC: 13.0 CHs. There were no CH/resident withdrawals. Forty (26.1%) participants were unavailable for follow-up: 28 died (12 MoveMore; 16 UC); 12 moved from the CH. Staff informant/proxy data collection for participants was >80%; data collection from participants was <75%; at 9 months, 65.6% of residents provided valid accelerometer data; two CHs fully, two partially and one failed to implement the intervention. There were no safety concerns. CONCLUSIONS Recruiting CHs and residents was feasible. Intervention implementation and data collection methods need refinement before a definitive trial. There were no safety concerns.
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Affiliation(s)
- Anne Forster
- Academic Unit for Ageing and Stroke Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, West Yorkshire, UK
| | - Jennifer Airlie
- Academic Unit for Ageing and Stroke Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Alison Ellwood
- Centre for Dementia Studies, University of Bradford, Bradford, UK
| | - Mary Godfrey
- Academic Unit for Ageing and Stroke Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, West Yorkshire, UK
| | - John Green
- Academic Unit for Ageing and Stroke Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Bonnie Cundill
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Claire Hulme
- Institute of Health Research, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Robert Cicero
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds UK
| | - Vicki McLellan
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds UK
| | - Liz Graham
- Academic Unit for Ageing and Stroke Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Bev Gallagher
- NHS Bradford District and Craven Clinical Commissioning Group, Bradford, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Joan Firth
- Patient and Public Involvement Contributor, Ilkley, UK
| | - Amanda Farrin
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds UK
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14
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Smith N, Liew Z, Johnson S, Ellard DR, Underwood M, Kearney R. A systematic review of the methods and drugs used for performing suprascapular nerve block injections for the non-surgical management of chronic shoulder pain. Br J Pain 2021; 15:460-473. [PMID: 34840794 PMCID: PMC8611295 DOI: 10.1177/2049463721992091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Suprascapular nerve block (SSNB) injections are growing in popularity as a treatment option for people with chronic shoulder pain. The optimal method of injection and aftercare is unknown. This review describes the current methods and drugs used for performing SSNB injections in the non-surgical management of adults with chronic shoulder pain in order to inform future research in this area. Systematic searches of CINAHL, MEDLINE (OVID), AMED, Embase databases and the Cochrane Library were undertaken from inception to June 2020. Data on the method and drugs used for injection and aftercare were extracted and summarised for areas of commonality and discrepancy. We included 53 studies in this review. In total, eight different injection methods were reported within the included studies. Indirect surface land-marked methods were the most common method reported in 21 studies. Direct surface land-marked methods were reported in 12 studies. Ultrasound-guided methods used alone were reported in 16 studies. Both fluoroscopy and computed tomography methods used alone were reported in one study each. Electromyography was used in combination with other injection methods in nine studies. Wide variation in the composition of the injectate was observed between studies. Local anaesthetic was used within injectate preparations in all studies. Local anaesthetic used alone was reported in 20 studies, combined with steroid in 29 studies and combined with various other components in 5 studies. Physiotherapy following injection was reported in 26 studies. Reported details of physiotherapy varied considerably. This review identified substantial variation in the methods and drugs used to perform SSNB injection in clinical trials. Current literature demonstrates a wide range of methods used for SSNB injection administration. Consensus research defining standardised practice for SSNB injection is now needed to guide future clinical practice and research.
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Affiliation(s)
- Neil Smith
- Warwick Clinical Trials Unit, The
University of Warwick, Coventry, UK
- Sandwell and West Birmingham Hospitals
NHS Trust, Physiotherapy Department, West Bromwich, UK
| | - Ziheng Liew
- Warwick Clinical Trials Unit, The
University of Warwick, Coventry, UK
| | - Samantha Johnson
- Warwick Clinical Trials Unit, The
University of Warwick, Coventry, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, The
University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, The
University of Warwick, Coventry, UK
| | - Rebecca Kearney
- Warwick Clinical Trials Unit, The
University of Warwick, Coventry, UK
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15
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Collard VEJ, Moore C, Nichols V, Ellard DR, Patel S, Sandhu H, Parsons H, Sharma U, Underwood M, Madan J, Tang NKY. Challenges and visions for managing pain-related insomnia in primary care using the hybrid CBT approach: a small-scale qualitative interview study with GPs, nurses, and practice managers. BMC Fam Pract 2021; 22:210. [PMID: 34666682 PMCID: PMC8527665 DOI: 10.1186/s12875-021-01552-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/01/2021] [Indexed: 08/30/2023]
Abstract
Background Chronic pain and insomnia have a complex, bidirectional relationship – addressing sleep complaints alongside pain may be key to alleviating patient-reported distress and disability. Healthcare professionals have consistently reported wanting to offer psychologically informed chronic pain management at the primary care level. Research in secondary care has demonstrated good treatment efficacy of hybrid CBT for chronic pain and insomnia. However, primary care is typically the main point of treatment entry, hence may be better situated to offer treatments using a multidisciplinary approach. In this study, primary care service providers’ perception of feasibility for tackling pain-related insomnia in primary care was explored. Methods The data corpus originates from a feasibility trial exploring hybrid CBT for chronic pain and insomnia delivered in primary care. This formed three in-depth group interviews with primary care staff (n = 9) from different primary care centres from the same NHS locale. All interviews were conducted on-site using a semi-structured approach. Verbal data was recorded, transcribed verbatim and analysed using the thematic analysis process. Results Eight themes were identified – 1) Discrepant conceptualisations of the chronic pain-insomnia relationship and clinical application, 2) Mismatch between patients’ needs and available treatment offerings, 3) Awareness of psychological complexities, 4) Identified treatment gap for pain-related insomnia, 5) Lack of funding and existing infrastructure for new service development, 6) General shortage of psychological services for complex health conditions, 7) Multidisciplinary team provision with pain specialist input, and 8) Accessibility through primary care. These mapped onto four domains - Current understanding and practice, Perceived facilitators, Perceived barriers, Ideal scenarios for a new treatment service – which reflected the focus of our investigation. Taken together these provide key context for understanding challenges faced by health care professionals in considering and developing a new clinical service. Conclusions Primary care service providers from one locale advocate better, multidisciplinary treatment provision for chronic pain and insomnia. Findings suggest that situating this in primary care could be a feasible option, but this requires systemic support and specialist input as well as definitive trials for success. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01552-3.
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Affiliation(s)
- V E J Collard
- Department of Psychology, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.
| | - C Moore
- Department of Psychology, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - V Nichols
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - D R Ellard
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - S Patel
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - H Sandhu
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - H Parsons
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - U Sharma
- University/User Teaching and Research Action Partnership, University of Warwick, Coventry, CV4 7AL, UK
| | - M Underwood
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
| | - J Madan
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - N K Y Tang
- Department of Psychology, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
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16
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Liew Z, Mazuquin B, Ellard DR, Karasouli E, Drew S, Modi C, Bush H, Underwood M, Kearney RS. Development of a single-session physiotherapy and self-management intervention for the treatment of primary traumatic anterior shoulder dislocation for the 'Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN)' multi centre RCT. Physiotherapy 2021; 113:80-87. [PMID: 34607077 PMCID: PMC8612274 DOI: 10.1016/j.physio.2021.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 05/04/2021] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Abstract
Objective Optimum physiotherapy management for people with a conservatively managed primary traumatic anterior shoulder dislocation is not known. The purpose of the ARTISAN trial is to compare the clinical and cost-effectiveness of a course of usual care physiotherapy with a single session of physiotherapy and self-management, the ARTISAN intervention. ARTISAN is a UK multi-centre, two-arm, parallel group, randomised controlled trial with 1:1 treatment allocation. Design The intervention was developed following the Medical Research Council framework for developing and evaluating complex interventions and will be reported in line with the template for intervention description and replication checklist (TIDieR) and the Consensus on Exercise Reporting Template (CERT). It was informed by published research, national clinical guidelines, current clinical practice and patient and public involvement. Results The ARTISAN intervention comprises education (Phase 1), progressive exercise (Phase 2 and Phase 3) and an optional return to sport component (Phase 4). Behaviour change strategies are embedded throughout intervention. The single session of physiotherapy is delivered by a chartered physiotherapist, within the first six weeks of injury, in an NHS outpatient setting. At the end of the initial session, paper-based booklets and/or a patient website with the same content are provided to participants to aid self-management and progression though the four phases of the trial intervention. Conclusion The ARTISAN intervention was successfully implemented throughout the internal pilot and is suitable for testing in the subsequent definitive RCT ARTISAN trial.
Trial Registration Number ISRCTN63184243
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Affiliation(s)
- ZiHeng Liew
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom.
| | - Bruno Mazuquin
- Manchester Metropolitan University, Manchester, M15 6BH, United Kingdom.
| | - David R Ellard
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom.
| | - Eleni Karasouli
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom.
| | - Stephen Drew
- University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| | - Chetan Modi
- University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| | - Howard Bush
- University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| | - Martin Underwood
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom; University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| | - Rebecca S Kearney
- University of Warwick, Clinical Trials Unit, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom; University Hospitals Coventry & Warwickshire NHS Trust, Trauma and Orthopaedics, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
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17
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Forster A, Godfrey M, Green J, McMaster N, Airlie J, Cundill B, Lawton R, Hawkins R, Hulme C, Birch K, Brown L, Cicero R, Crocker TF, Dawkins B, Ellard DR, Ellwood A, Firth J, Gallagher B, Graham L, Johnson L, Lusambili A, Marti J, McCrorie C, McLellan V, Patel I, Prashar A, Siddiqi N, Trépel D, Wheeler I, Wright A, Young J, Farrin A. Strategies to enhance routine physical activity in care home residents: the REACH research programme including a cluster feasibility RCT. Programme Grants Appl Res 2021. [DOI: 10.3310/pgfar09090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Care home residents are mainly inactive, leading to increased dependency and low mood. Although exercise classes may increase activity, a more sustainable model is to engage staff and residents in increasing routine activity.
Objectives
The objectives were to develop and preliminarily test strategies to enhance the routine physical activity of care home residents to improve their physical, psychological and social well-being through five overlapping workstreams.
Design
This trial had a mixed-methods research design to develop and test the feasibility of undertaking an evaluative study consisting of gaining an understanding of the opportunities for and barriers to enhancing physical activity in care homes (workstream 1); testing physical activity assessment instruments (workstream 2); developing an intervention through a process of intervention mapping (workstream 3); refining the provisional intervention in the care home setting and clarifying outcome measurement (workstream 4); and undertaking a cluster randomised feasibility trial of the intervention [introduced via three facilitated workshops at baseline (with physiotherapist input), 2 weeks (with artist input) and 2 months], with embedded process and health economic evaluations (workstream 5).
Setting
The trial was set in 12 residential care homes differing in size, location, ownership and provision in Yorkshire, UK.
Participants
The participants were elderly residents, carers, managers and staff of care homes.
Intervention
The intervention was MoveMore, designed for the whole home, to encourage and support the movement of residents in their daily routines.
Main outcome measures
The main outcome measures related to the feasibility and acceptability of implementing a full-scale trial in terms of recruitment and retention of care homes and residents, intervention delivery, completion and reporting of baseline data and outcomes (including hours of accelerometer wear, hours of sedentary behaviour and hours and type of physical activity), and safety and cost data (workstream 5).
Results
Workstream 1 – through a detailed understanding of life in a care home, a needs assessment was produced, and barriers to and facilitators of activity were identified. Key factors included ethos of care; organisation, management and delivery of care; use of space; and the residents’ daily routines. Workstream 2 – 22 (73.3%) out of 30 residents who wore a hip accelerometer had valid data (≥ 8 hours on ≥ 4 days of the week). Workstream 3 – practical mechanisms for increasing physical activity were developed, informed by an advisory group of stakeholders and outputs from workstreams 1 and 2, framed by the process of intervention mapping. Workstream 4 – action groups were convened in four care homes to refine the intervention, leading to further development of implementation strategies. The intervention, MoveMore, is a whole-home intervention involving engagement with a stakeholder group to implement a cyclical process of change to encourage and support the movement of residents in their daily routines. Workstream 5 – 12 care homes and 153 residents were recruited to the cluster randomised feasibility trial. Recruitment in the care homes varied (40–89%). Five care homes were randomised to the intervention and seven were randomised to usual care. Predetermined progression criteria were recruitment of care homes and residents (green); intervention delivery (amber); and data collection and follow-up – 52% of residents provided usable accelerometer data at 9 months (red), > 75% of residents had reported outcomes at 9 months (green, but self-reported resident outcomes were red), 26% loss of residents to follow-up at 9 months [just missing green criterion (no greater than 25%)] and safety concerns (green).
Limitations
Observations of residents’ movements were not conducted in private spaces. Working with care home residents to identify appropriate outcome measures was challenging. Take-up of the intervention was suboptimal in some sites. It was not possible to make a reliably informed decision on the most appropriate physical activity end point(s) for future use in a definitive trial.
Conclusions
A whole-home intervention was developed that was owned and delivered by staff and was informed by residents and staff. The feasibility of conducting a cluster randomised controlled trial was successfully tested: the target numbers of care homes and residents were recruited, demonstrating that it is possible to recruit care home residents to a cluster randomised trial, although this process was time-consuming and resource heavy. A large data set was collected, which provided a comprehensive picture of the environment, residents and staff in care homes. Extensive quantitative and qualitative work comprehensively explored a neglected area of health and social care research. Completion of ethnographic work in a range of settings enabled the production of an in-depth picture of life in care homes that will be helpful for other researchers considering organisational change in this setting.
Future work
The content and delivery of the intervention requires optimisation and the outcome measurement requires further refinement prior to undertaking a full trial evaluation. Consideration could be given to a recommended, simplified, core outcome set, which would facilitate data collection in this population.
Trial registration
Current Controlled Trials ISRCTN16076575.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grant for Applied Research programme and will be published in full in Programme Grant for Applied Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anne Forster
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Mary Godfrey
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - John Green
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Jennifer Airlie
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Bonnie Cundill
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rebecca Hawkins
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Claire Hulme
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Karen Birch
- Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Lesley Brown
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Robert Cicero
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Thomas Frederick Crocker
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, School of Medicine, University of Leeds, Leeds, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Alison Ellwood
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Joan Firth
- Patient and public involvement contributor, Ilkley, UK
| | - Bev Gallagher
- Bradford District and Craven Clinical Commissioning Group, Bradford, UK
| | - Liz Graham
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Adelaide Lusambili
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Joachim Marti
- University Institute of Social and Preventive Medicine, Lausanne, Switzerland
| | - Carolyn McCrorie
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Vicki McLellan
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ismail Patel
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Arvin Prashar
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Najma Siddiqi
- Hull York Medical School, Department of Health Sciences, University of York, York, UK
| | - Dominic Trépel
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Ian Wheeler
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Alan Wright
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - John Young
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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McKeown R, Parsons H, Ellard DR, Kearney RS. An evaluation of the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture. Physiotherapy 2021; 112:1-8. [PMID: 34000602 DOI: 10.1016/j.physio.2021.03.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate the measurement properties of the Olerud Molander Ankle Score in adults with an ankle fracture. METHODS Patients completed outcome measure questionnaires at baseline, six, 10- and 16-weeks postinjury as part of an ongoing clinical trial on ankle fracture rehabilitation. The internal consistency, convergent validity, structural validity and interpretability of the Olerud Molander Ankle Score was assessed. This was achieved through using the respective analysis methods of Cronbach's alpha, correlation coefficients, principal component analysis, evaluation of floor and ceiling scores and estimation of the minimally important change using anchor-based methods. RESULTS The Olerud Molander Ankle Score showed adequate convergent validity against hypotheses set in relation to scores of comparator instruments. Principal component analysis demonstrated that the measure has two subscales: ankle function and ankle symptoms. The internal consistency of the measure and the ankle function subscale was sufficient, but inconclusive for the ankle symptoms subscale. There were no floor and ceiling effects present within the scores and the estimated minimally important change was 9.7 points. CONCLUSION The Olerud Molander Ankle Score demonstrates sufficient measurement properties and is likely to be primarily measuring the construct of patient reported function following ankle fracture. Further research should evaluate the relevance of other domains to individuals recovering from and ankle fracture, such as social participation and psychological wellbeing. The development of a core outcome set would be advantageous to standardise outcome measurement collection in this area.
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Affiliation(s)
- Rebecca McKeown
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, United Kingdom.
| | - Helen Parsons
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, United Kingdom.
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick and University Hospitals Coventry and Warwickshire, United Kingdom.
| | - Rebecca S Kearney
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick and University Hospitals Coventry and Warwickshire, United Kingdom.
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Froud R, Grant M, Burton K, Foss J, Ellard DR, Seers K, Smith D, Barillec M, Patel S, Haywood K, Underwood M. Development and feasibility of an intervention featuring individual supported work placements to aid return to work for unemployed people living with chronic pain. Pilot Feasibility Stud 2020; 6:49. [PMID: 32337065 PMCID: PMC7175501 DOI: 10.1186/s40814-020-00581-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 03/10/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Working in good jobs is associated with good health. High unemployment rates are reported in those disabled with musculoskeletal pain. Supported employment interventions work well for helping people with mental health difficulties to gain and retain employment. With adaptation, these may be useful for people with chronic pain. We aimed to develop and explore the feasibility of delivering such an adapted intervention. METHODS We developed an intervention and recruited unemployed people with chronic pain from NHS pain clinics and employment services. We trained case managers to assess participants and match them to six-week work placements in the Midlands and provide ongoing support to them and their managers. Participants attended a two-day work preparation session prior to placement. Outcome measures included quality of life at baseline, six- weeks, 14-weeks, and six-months, and return to work at 14-weeks and six-months. We held focus groups or interviews with stakeholders to examine acceptability and experiences of the intervention. RESULTS We developed an intervention consisting of work preparation sessions, work experience placements, and individualised employment support. We enrolled 31 people; 27 attended work preparation sessions, and 15 attended placements. Four of our participants started jobs during the study period. We are aware of two others starting jobs shortly after cessation of follow-up. We experienced challenges to recruitment in one area where we had many and diverse placement opportunities and good recruitment in another area where we had a smaller range of placement opportunities. All stakeholders found the intervention acceptable, and it was valued by those given a placement. While there was some disappointment among those not placed, this group still valued the work preparation sessions. CONCLUSIONS The developed intervention was acceptable to participants and partners. Trialling the developed intervention could be feasible with attention to three main processes. To ensure advanced availability of a sufficiently wide range of work placements in each area, multiple partners would be needed. Multiple recruitment sites and focus on employment services will yield better recruitment rates than reliance on NHS pain clinics. Maintaining an adequate follow-up response rate will likely require additional approaches with more than the usual effort.
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Affiliation(s)
- Robert Froud
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
- Institute of Health Sciences, Kristiania University College, Prinsens Gate 7-9, 0152 Oslo, Norway
| | - Mary Grant
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Kim Burton
- Centre for Applied Research in Health, School of Human & Health Sciences, The University of Huddersfield, Queensgate, Huddersfield, HD1 3DH UK
| | - Jonathan Foss
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - David R. Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Kate Seers
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Deb Smith
- University/User Teaching and Research Action Partnership, University of Warwick, Coventry, UK
| | - Mariana Barillec
- Serco UK & Europe; Employment, Skills and Enterprise, Trigate Business Centre, 210-222 Hagley Road West, Birmingham, B68 0NP UK
| | - Shilpa Patel
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Kirstie Haywood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL UK
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
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Patel S, Achana F, Carnes D, Eldridge S, Ellard DR, Griffiths F, Haywood K, Hee SW, Mistry D, Mistry H, Nichols VP, Petrou S, Pincus T, Potter R, Sandhu HK, Stewart K, Taylor S, Underwood M, Matharu M. Usual care and a self-management support programme versus usual care and a relaxation programme for people living with chronic headache disorders: a randomised controlled trial protocol (CHESS). BMJ Open 2020; 10:e033520. [PMID: 32284387 PMCID: PMC7200026 DOI: 10.1136/bmjopen-2019-033520] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Chronic headaches are poorly diagnosed and managed and can be exacerbated by medication overuse. There is insufficient evidence on the non-pharmacological approaches to helping people living with chronic headaches. METHODS AND ANALYSIS Chronic Headache Education and Self-management Study is a pragmatic randomised controlled trial to test the effectiveness and cost-effectiveness of a self-management education support programme on top of usual care for patients with chronic headaches against a control of usual care and relaxation. The intervention is a 2-day group course based on education, personal reflection and a cognitive behavioural approach, plus a nurse-led one-to-one consultation and follow-up over 8 weeks. We aim to recruit 689 participants (356 to the intervention arm and 333 to the control) from primary care and self-referral in London and the Midlands. The trial is powered to show a difference of 2.0 points on the Headache Impact Test, a patient-reported outcome measure at 12 months post randomisation. Secondary outcomes include health related quality of life, self-efficacy, social activation and engagement, anxiety and depression and healthcare utilisation. Outcomes are being measured at 4, 8 and 12 months. Cost-effectiveness will be expressed in terms of incremental cost per quality-adjusted life year gained. ETHICS AND DISSEMINATION This trial will provide data on effectiveness and cost-effectiveness of a self-management support programme for chronic headaches. The results will inform commissioning of services and clinical practice. North West - Greater Manchester East Research Ethics Committee have approved the trial. The current protocol version is 3.6 date 7 March 2019. TRIAL REGISTRATION NUMBER ISRCTN79708100.
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Affiliation(s)
- Shilpa Patel
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Felix Achana
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dawn Carnes
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - David R Ellard
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Frances Griffiths
- Warwick Medical School, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Kirstie Haywood
- Warwick Medical School, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Siew Wan Hee
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dipesh Mistry
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Hema Mistry
- Warwick Medical School, Warwick Evidence, University of Warwick, Coventry, UK
| | - Vivien P Nichols
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Tamar Pincus
- Department of Psychology, Royal Holloway University of London, Egham, UK
| | - Rachel Potter
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | - Kimberley Stewart
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Stephanie Taylor
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Martin Underwood
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Manjit Matharu
- University College London Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
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Tang NKY, Moore C, Parsons H, Sandhu HK, Patel S, Ellard DR, Nichols VP, Madan J, Collard VEJ, Sharma U, Underwood M. Implementing a hybrid cognitive-behavioural therapy for pain-related insomnia in primary care: lessons learnt from a mixed-methods feasibility study. BMJ Open 2020; 10:e034764. [PMID: 32193269 PMCID: PMC7150590 DOI: 10.1136/bmjopen-2019-034764] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To test the feasibility of implementing a brief but intensive hybrid cognitive behavioural therapy (Hybrid CBT) for pain-related insomnia. DESIGN Mixed-methods, with qualitative process evaluation on a two-arm randomised controlled feasibility trial. SETTING Primary care. PARTICIPANTS Twenty-five adult patients with chronic pain and insomnia. INTERVENTION Hybrid CBT or self-help control intervention. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes measures were the Insomnia Severity Index and interference scale of the Brief Pain Inventory (BPI). Secondary outcomes measures were the present pain intensity rating from the BPI, Multidimensional Fatigue Inventory, Hospital Anxiety and Depression Scale and EQ-5D-5L. RESULTS Fourteen participants were randomised to receive Hybrid CBT, 11 to receive the self-help control treatment. Of the 14 in the Hybrid CBT group, 9 (64%) completed all four treatment sessions (4 discontinued due to poor health; 1 due to time constraints). Adherence to the self-help control treatment was not monitored. The total number of participants completing the 12-week and 24-week follow-ups were 12 (6 in each group; Hybrid CBT: 43%; self-help: 55%) and 10 (5 in each group; Hybrid CBT: 36%; self-help: 45%). Based on the data available, candidate outcome measures appeared to be sensitive to changes associated with interventions. Thematic analysis of pre-postintervention interview data revealed satisfaction with treatment content among those who completed the Hybrid CBT, whereas those in the self-help control treatment wanted more contact hours and therapist guidance. Other practical suggestions for improvement included shortening the duration of each treatment session, reducing the amount of assessment paperwork, and minimising the burden of sleep and pain monitoring. CONCLUSION Important lessons were learnt with regard to the infrastructure required to achieve better patient adherence and retention. Based on the qualitative feedback provided by a subset of treatment completers, future trials should also consider lowering the intensity of treatment and streamlining the data collection procedure. TRIAL REGISTRATION NUMBER ISRCTN17294365.
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Affiliation(s)
- Nicole K Y Tang
- Department of Psychology, University of Warwick, Coventry, West Midlands, UK
| | - Corran Moore
- Department of Psychology, University of Leicester, Leicester, Leicestershire, UK
| | - Helen Parsons
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, West Midlands, UK
| | - Harbinder Kaur Sandhu
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, West Midlands, UK
| | - Shilpa Patel
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, West Midlands, UK
| | - David R Ellard
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, West Midlands, UK
| | - Vivien P Nichols
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, West Midlands, UK
| | - Jason Madan
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, West Midlands, UK
| | | | - Uma Sharma
- Patient Representative, Coventry, West Mindlands, UK
| | - Martin Underwood
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, West Midlands, UK
- University Hospitals of Coventry and Warwickshire, Coventry, West Midlands, UK
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Hughes C, Ellard DR, Campbell A, Potter R, Shaw C, Gardner E, Agus A, O'Reilly D, Underwood M, Loeb M, Stafford B, Tunney M. Developing evidence-based guidance for assessment of suspected infections in care home residents. BMC Geriatr 2020; 20:59. [PMID: 32059649 PMCID: PMC7023778 DOI: 10.1186/s12877-020-1467-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to update and refine an algorithm, originally developed in Canada, to assist care home staff to manage residents with suspected infection in the United Kingdom care home setting. The infections of interest were urinary tract infections, respiratory tract infections and skin and soft tissue infection. METHOD We used a multi-faceted process involving a literature review, consensus meeting [nominal group technique involving general practitioners (GPs) and specialists in geriatric medicine and clinical microbiology], focus groups (care home staff and resident family members) and interviews (GPs), alongside continual iterative internal review and analysis within the research team. RESULTS Six publications were identified in the literature which met inclusion criteria. These were used to update the algorithm which was presented to a consensus meeting (four participants all with a medical background) which discussed and agreed to inclusion of signs and symptoms, and the algorithm format. Focus groups and interview participants could see the value in the algorithm, and staff often reported that it reflected their usual practice. There were also interesting contrasts between evidence and usual practice informed by experience. Through continual iterative review and analysis, the final algorithm was finally presented in a format which described management of the three infections in terms of initial assessment of the resident, observation of the resident and action by the care home staff. CONCLUSIONS This study has resulted in an updated algorithm targeting key infections in care home residents which should be considered for implementation into everyday practice.
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Affiliation(s)
- Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK.
| | - David R Ellard
- Warwick Clinical Trials Unit, The University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Anne Campbell
- Faculty of Medicine, Department of Infectious Diseases, Imperial College London, London, UK
| | - Rachel Potter
- Warwick Clinical Trials Unit, The University of Warwick, Coventry, UK
| | - Catherine Shaw
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Evie Gardner
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, The University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | | | - Michael Tunney
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Abstract
OBJECTIVE The objective of this qualitative research study is to explore patient experiences of ankle fracture and the factors most important to them in recovery. DESIGN Semistructured interviews exploring patient experiences of ankle fracture recovery at 16-23 weeks following injury. Interviews followed a topic guide and were recorded with an encrypted audio recorder and then transcribed verbatim. Thematic content analysis was used to identify themes in the data. SETTING Individuals were recruited from a sample of participants of a UK-based clinical trial of immobilisation methods for ankle fracture (ISRCTN15537280 at the pre-results stage at time of writing). Interviews were conducted at the participants' own homes or on a university campus setting. PARTICIPANTS A purposive sample was used to account for key variables of age, gender and fracture management. Participants recruited from the clinical trial sample were adults aged 18 years or over with a closed ankle fracture. RESULTS Ten participants were interviewed, five of whom were female and six of whom needed an operation to fix their ankle fracture. The age range of participants was 21-75 years with a mean of 51.6 years. Eight themes emerged from the data during analysis; mobility, loss of independence, healthcare, psychological effects, social and family life, ankle symptoms, sleep disturbance and fatigue, and activities of daily living. Factors of importance to participants included regaining their independence, sleep quality and quantity, ability to drive, ability to walk without walking aids or weight-bearing restrictions, and radiological union. CONCLUSIONS The results of this research demonstrates the extensive impact of ankle fracture on individuals' lives, including social and family life, sleep, their sense of independence and psychological well-being. The results of this study will enable an increased understanding of the factors of relevance to individuals with ankle fracture, allowing collection of appropriate outcomes in clinical studies for this condition. Ultimately these results will help formulate appropriate patient-centred rehabilitation plans for these patients. TRIAL REGISTRATION NUMBER ISRCTN15537280; Pre-results.
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Affiliation(s)
- Rebecca McKeown
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Rebecca Samantha Kearney
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
- University Hospitals Coventry and Warwickshire, Coventry, West Midlands, UK
| | - Zi Heng Liew
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
- University Hospitals Coventry and Warwickshire, Coventry, West Midlands, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
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McKeown R, Ellard DR, Rabiu AR, Karasouli E, Kearney RS. A systematic review of the measurement properties of patient reported outcome measures used for adults with an ankle fracture. J Patient Rep Outcomes 2019; 3:70. [PMID: 31848877 PMCID: PMC6917678 DOI: 10.1186/s41687-019-0159-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/05/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ankle fractures are painful and debilitating injuries that pose a significant burden to society and healthcare systems. Patient reported outcome measures (PROMs) are commonly used outcome measures in clinical trials of interventions for ankle fracture but there is little evidence on their validity and reliability. This systematic review aims to identify and appraise evidence for the measurement properties of ankle specific PROMs used in adults with an ankle fracture using Consensus Based Standards for the Selection of Health Measurement Instrument (COSMIN) methodology. METHODS We searched MEDLINE, Embase and CINAHL online databases for evidence of measurement properties of ankle specific PROMs. Articles were included if they assessed or described the development of the PROM in adults with ankle fracture. Articles were ineligible if they used the PROM to assess the measurement properties of another instrument. Abstracts without full articles and conference proceedings were ineligible, as were articles that adapted the PROM under evaluation without any formal justification of the changes as part of a cross-cultural validation or translation process. Two reviewers completed the screening. To assess methodological quality we used COSMIN risk of bias checklist and summarised evidence using COSMIN quality criteria and a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Two reviewers assessed the methodological quality and extracted the data for a sample of articles. RESULTS The searches returned a total of 377 articles. From these, six articles were included after application of eligibility criteria. These articles evaluated three PROMs: A-FORM, OMAS and AAOS. The A-FORM had evidence of a robust development process within the patient population, however lacks post-formulation testing. The OMAS showed sufficient levels of reliability, internal consistency and construct validity. The AAOS showed low quality evidence of sufficient construct validity. CONCLUSIONS There is insufficient evidence to support the recommendation of a particular PROM for use in adult ankle fracture research based on COSMIN methodology. Further validation of these outcome measures is required in order to ensure PROMs used in this area are sufficiently valid and reliable to assess treatment effects. This would enable high quality, evidenced-based management of adults with ankle fracture.
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Affiliation(s)
- Rebecca McKeown
- Warwick Clinical Trials Unit, Warwick Medical School, Clinical Sciences Research Laboratories, University of Warwick, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK.
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, Clinical Sciences Research Laboratories, University of Warwick, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Abdul-Rasheed Rabiu
- Trauma and Orthopaedics Department, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Eleni Karasouli
- Warwick Clinical Trials Unit, Warwick Medical School, Clinical Sciences Research Laboratories, University of Warwick, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Rebecca S Kearney
- Warwick Clinical Trials Unit, Warwick Medical School, Clinical Sciences Research Laboratories, University of Warwick, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
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Potter R, Campbell A, Ellard DR, Shaw C, Gardner E, Agus A, O'Reilly D, Underwood M, Loeb M, Stafford B, Tunney M, Hughes C. Multifaceted intervention to Reduce Antimicrobial Prescribing in Care Homes: a process evaluation of a UK-based non-randomised feasibility study. BMJ Open 2019; 9:e032185. [PMID: 31753887 PMCID: PMC6887004 DOI: 10.1136/bmjopen-2019-032185] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/09/2019] [Accepted: 09/23/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To explore the facilitators and obstacles to the development and implementation of the Reduce Antimicrobial Prescribing in Care Homes intervention. DESIGN We used a mixed-methods approach. We conducted focus groups with care home staff and relatives of residents, and interviews with general practitioners (GPs) and home managers, completed observational visits and collected demographic data, training attendance records and data on the use of a decision-making algorithm. We used normalisation process theory to inform topic guides and interpretation of the data. SETTING Six care homes, three in Northern Ireland and three in the West Midlands, England. INTERVENTION A decision-making algorithm for urinary tract, respiratory tract and skin and soft-tissue infections, plus small group interactive training for care home staff. RESULTS We ran 21 training sessions across the six homes and trained 35/42 (83%) of nurses and 101/219 (46%) of all care staff. Care home staff reported using the decision-making algorithm 81 times. Postimplementation, staff reported being more knowledgeable about antimicrobial resistance but were unsure if the intervention would change how GPs prescribed antimicrobials. The pressures of everyday work in some homes meant that engagement was challenging at times. Staff felt that some of the symptoms included in decision-making algorithm, despite being evidence based, were not easy to detect in residents with dementia or urinary incontinence. Some staff did not use the decision-making algorithm, noting that their own knowledge of the resident was more important. CONCLUSION We delivered a training package to a substantial number of key staff in care homes. A decision-making algorithm for common infections in care homes empowered staff but was challenging to operationalise at times. A future study should consider the findings from the process evaluation to help ensure the successful implementation on a larger scale.
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Affiliation(s)
- Rachel Potter
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Campbell
- Health Protection Research Unit, Imperial College London, London, UK
| | - David R Ellard
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospital Coventry and Warwickshire, Coventry, UK
| | - Catherine Shaw
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Evie Gardner
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Martin Underwood
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospital Coventry and Warwickshire, Coventry, UK
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Michael Tunney
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Williamson SZ, Johnson R, Sandhu HK, Ellard DR, Jenkins J, Casey M, Kearins O, Taylor-Phillips S. Communicating biopsy results from breast screening assessment: current practice in English breast screening centres and staff perspectives of telephoning results. BMJ Open 2019; 9:e028683. [PMID: 31699718 PMCID: PMC6858119 DOI: 10.1136/bmjopen-2018-028683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To record how breast screening centres in England deliver all biopsy results (cancer/non-cancer) from the breast assessment visit. DESIGN Online survey of 63 of 79 breast screening centres in England from all regions (East Midlands, East of England, London, North East Yorkshire & Humber, North West, South East, South West, West Midlands). The survey contained quantitative measures of frequency for telephoning biopsy results (routinely, occasionally or never) and optional qualitative free-text responses. Surveys were completed by a staff member from each centre. RESULTS There were no regional trends in the use of telephone results services, (X² (14, n=63)=11.55, p=0.64), Centres who telephoned results routinely did not deliver results sooner than centres who deliver results in-person (X² (16, n=63)=12.76, p=0.69).When delivering cancer results, 76.2% of centres never telephone results and 23.8% of centres occasionally telephone results. No centres reported delivering cancer results routinely by telephone. Qualitative content analysis suggests that cancer results are only telephoned at the patient request and under exceptional circumstances.When delivering non-cancer results, 12.7% of centres never telephoned results, 38.1% occasionally telephoned results and 49.2% routinely telephoned results. Qualitative content analysis revealed different processes for delivering telephone results, including patient choice and scheduling an in-person results appointment for all women attending breast assessment, then ringing non-cancer results unexpectedly ahead of this prebooked appointment. CONCLUSIONS In the National Health Service Breast Screening Programme, breast assessment results that are cancer are routinely delivered in-person. However, non-cancer breast assessment results are often routinely delivered by telephone, despite breast screening policy recommendations. More research is needed to understand the impact of telephoning results on women attending breast assessment, particularly women who receive a non-cancer result. Future research should also consider how women themselves might prefer to receive their results.
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Affiliation(s)
| | - Rebecca Johnson
- School of Nursing, Midwifery and Health, Coventry University, Coventry, UK
| | - Harbinder K Sandhu
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK
| | - David R Ellard
- Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK
| | - Jacquie Jenkins
- NHS Breast Screening Programme, Public Health England, Sheffield, UK
| | | | - Olive Kearins
- National Lead Breast Screening QA, Public Health England, Birmingham, UK
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McKeown R, Rabiu AR, Ellard DR, Kearney RS. Primary outcome measures used in interventional trials for ankle fractures: a systematic review. BMC Musculoskelet Disord 2019; 20:388. [PMID: 31455297 PMCID: PMC6712770 DOI: 10.1186/s12891-019-2770-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 08/19/2019] [Indexed: 12/19/2022] Open
Abstract
Background Ankle fractures cause considerable pain, loss of function and healthcare resource use. High quality randomised controlled trials are required to evaluate the optimal management protocols for ankle fracture. However, there is debate regarding the most appropriate outcome measure to use when assessing patients with ankle fractures. The aim of this systematic review is to identify and summarise primary outcome measure use in clinical trials of non-pharmacological interventions for adults with an ankle fracture. Methods We performed comprehensive searches of the Medline, Embase, CINAHL, AMED and Cochrane CENTRAL databases, as well as ISRCTN and ClinicalTrials.gov online clinical trial registries on 19/06/2019 with no date limits applied. The titles and abstracts were initially screened to identify randomised or quasi-randomised clinical trials of non-pharmacological interventions for ankle fracture in adults. Two authors independently screened the full text of any articles which could potentially be eligible. Descriptive statistics we used to summarise the outcome measures collected in these articles including an assessment of trends over time. Secondary analysis included a descriptive summary of the multi-item patient reported outcome measures used in this study type. Results The searches returned a total of 3380 records. Following application of the eligibility criteria, 121 records were eligible for inclusion in this review. The most frequently collected primary outcome measures in this type of publication was the Olerud Molander Ankle Score, followed by radiographic and range of movement assessments. There was a total of 28 different outcome measures collected and five different multi-item, patient reported outcome measures collected as the primary outcome measure. There was a sequential increase in the number of this type of study published per decade since the 1980’s. Conclusion This review demonstrates the wide range of measurement methods used to assess outcome in adults with an ankle fracture. Future research should focus on establishing the validity and reliability of the outcome measures used in this patient population. Formulation of a consensus based core outcome set for adults with an ankle fracture would be advantageous for ensuring homogeneity across studies in order to meta-analyse trial results. Electronic supplementary material The online version of this article (10.1186/s12891-019-2770-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca McKeown
- Warwick Medical School, Warwick Clinical Trials Unit, University of Warwick, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Abdul-Rasheed Rabiu
- Trauma and Orthopaedics Department, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - David R Ellard
- Warwick Medical School, Warwick Clinical Trials Unit, University of Warwick, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Rebecca S Kearney
- Warwick Medical School, Warwick Clinical Trials Unit, University of Warwick, Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK
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Nichols VP, Ellard DR, Griffiths FE, Underwood M, Taylor SJC, Patel S. The CHESS trial: protocol for the process evaluation of a randomised trial of an education and self-management intervention for people with chronic headache. Trials 2019; 20:323. [PMID: 31164158 PMCID: PMC6549347 DOI: 10.1186/s13063-019-3372-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/19/2019] [Indexed: 11/22/2022] Open
Abstract
Background Process evaluation is increasingly common alongside complex randomised controlled trials (RCTs). This evaluation helps in understanding the mechanisms of impact and how the study processes were executed, and it includes any contextual factors which may have implications for the trial results and any future implementation. This process evaluation is for the Chronic Headache Education and Self-management Study (CHESS) RCT, which is evaluating an education and self-management group behavioural intervention for people with chronic headache. Chronic headache is defined as headaches which are present for 15 or more days per month. The most common types are chronic migraine and chronic tension type and medication overuse headaches. Methods We will use a mixed methods approach. Quantitative data will be taken from routine trial data which will help us to assess the reach of the study; i.e. did we reach those whom we expected and from where? Intervention attendance (dose received) and attrition and qualitative data will augment our understanding about reasons why people may not wish to take part in or failed to attend sessions. Interviews with intervention facilitators and trial participants will gain different perspectives on taking part in the trial. Fidelity will be assessed through listening to audio recordings for adherence to course content and competence of the facilitation of a sample of sessions. Discussion Our process evaluation will allow us to gain insight into how the trial was delivered, the obstacles and enablers encountered and the possible reasons why the interventions may or may not be effective. Trial registration ISRCTN79708100. Registered on 16 December 2015. Electronic supplementary material The online version of this article (10.1186/s13063-019-3372-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vivien P Nichols
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Frances E Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Stephanie J C Taylor
- Complex Intervention and Social Practice in Health Care unit, Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AB, UK
| | - Shilpa Patel
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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Ellwood A, Airlie J, Cicero R, Cundill B, Ellard DR, Farrin A, Godfrey M, Graham L, Green J, McLellan V, Siddiqi N, Forster A. Recruiting care homes to a randomised controlled trial. Trials 2018; 19:535. [PMID: 30285850 PMCID: PMC6169108 DOI: 10.1186/s13063-018-2915-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 09/12/2018] [Indexed: 11/24/2022] Open
Abstract
Background There are more than a quarter of a million individuals aged ≥ 65 years who are resident in care homes in England and Wales. Care home residents have high levels of cognitive impairment, physical disability, multimorbidity and polypharmacy. Research is needed to ensure there are robust, evidence-based interventions to improve the quality of life of this frail group. However, there is a paucity of research studies in this area. Recruiting care homes and their residents to research is challenging. A feasibility, cluster randomised controlled trial was undertaken as part of a research programme to identify ways to develop and test methods to enhance the physical activity of care home residents. This paper describes two methods of recruiting care homes to the trial and draws out learning to inform future studies. Methods Eligible care homes met the following criteria: they were within a defined geographical area in the north of England; provided residential care for adults ≥ 65 years of age; had not previously been involved in the research programme; were not taking part in a conflicting study; were not recorded on the Care Quality Commission website as ‘inadequate’ or ‘requiring improvements’ in any area; and had ≥ 10 beds. Care homes were identified by a ‘systematic approach’ using the Care Quality Commission website database of care homes or a ‘targeted approach’ via a network of research-ready care homes. A standardised method was used to recruit care homes including eligibility screening; invitation letters; telephone contact; visits; formal letter of agreement. Results In the systematic approach, 377 care homes were screened, 230 (61%) were initially eligible and invited to participate, 11 were recruited (recruitment rate (RR) 4.8%). In the targeted approach, 15 care homes were invited to participate, two were recruited (RR 13.3%). Overall, 245 care homes were approached and 13 recruited (RR 5.3%). A variety of care homes were recruited to the trial in terms of size, location, ownership and care provision. Conclusions Systematic recruitment of care homes to the study was time-consuming and resource-heavy but led to a variety of care homes being recruited. The targeted approach led to a higher recruitment rate. Trial registration ISRCTN registry, ISRCTN16076575. Registered on 25 June 2015.
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Affiliation(s)
- Alison Ellwood
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, BD9 6RJ, UK.
| | - Jennifer Airlie
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, BD9 6RJ, UK.,School of Biomedical Sciences, University of Leeds, Garstang Building, Leeds, LS2 9JT, UK
| | - Robert Cicero
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Bonnie Cundill
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Mary Godfrey
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, BD9 6RJ, UK.,Leeds Institute of Health Sciences, University of Leeds, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Liz Graham
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, BD9 6RJ, UK
| | - John Green
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, BD9 6RJ, UK
| | - Vicki McLellan
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Najma Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, ARRC Building, Heslington, York, YO10 5DD, UK
| | - Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, BD9 6RJ, UK.,Leeds Institute of Health Sciences, University of Leeds, Level 10, Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
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30
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Ellard DR, Underwood M, Achana F, Antrobus JH, Balasubramanian S, Brown S, Cairns M, Griffin J, Griffiths F, Haywood K, Hutchinson C, Lall R, Petrou S, Stallard N, Tysall C, Walsh DA, Sandhu H. Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial. Health Technol Assess 2018. [PMID: 28639551 DOI: 10.3310/hta21300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. OBJECTIVES To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. DESIGN The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. SETTING Five NHS acute trusts in England. PARTICIPANTS Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone. INTERVENTIONS All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. MAIN OUTCOME MEASURES Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. RESULTS Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. LIMITATIONS Poor recruitment was a limiting factor. CONCLUSIONS This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain. FUTURE WORK Further work is needed to test recruitment from alternative clinical situations. TRIAL REGISTRATION EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Felix Achana
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - James Hl Antrobus
- South Warwickshire NHS Foundation Trust, Warwick Hospital, Warwick, UK
| | - Shyam Balasubramanian
- Pain Management Service, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Sally Brown
- University/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - Melinda Cairns
- Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - James Griffin
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Frances Griffiths
- Social Science and Systems in Health, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Kirstie Haywood
- Royal College of Nursing Research Institute, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Hutchinson
- Population Evidence and Technologies Room, Warwick Medical School, University of Warwick, University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Colin Tysall
- University/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - David A Walsh
- Arthritis Research UK Pain Centre, Academic Rheumatology, University of Nottingham, Nottingham, UK
| | - Harbinder Sandhu
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Abstract
OBJECTIVE To systematically review the qualitative literature of the lived experience of people with a chronic headache disorder. BACKGROUND Chronic headaches affect 3%-4% of the population. The most common chronic headache disorders are chronic migraine, chronic tension-type headache and medication overuse headache. We present a systematic review and meta-ethnographic synthesis of the lived experience of people with chronic headache. METHODS We searched seven electronic databases, hand-searched nine journals and used a modified Critical Appraisal Skills Programme checklist to appraise study quality. Following thematic analysis we synthesised the data using a meta-ethnographic approach. RESULTS We identified 3586 unique citations; full texts were examined for 86 studies and 4 were included in the review. Included studies differed in their foci: exploring, patient-centred outcomes, chronic headache as a socially invisible disease, psychological processes mediating impaired quality of life, and the process of medication overuse. Initial thematic analysis and subsequent synthesis gave three overarching themes: 'headache as a driver of behaviour' (directly and indirectly), 'the spectre of headache' and 'strained relationships'. CONCLUSION This meta-synthesis of published qualitative evidence demonstrates that chronic headaches have a profound effect on people's lives, showing similarities with other pain conditions. There were insufficient data to explore the similarities and differences between different chronic headache disorders.
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Affiliation(s)
- Vivien P Nichols
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Frances E Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Atiya Kamal
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Stephanie J C Taylor
- Complex Intervention and Social Practice in Health Care Unit, Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Coventry, UK
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Ellard DR, Chimwaza W, Davies D, Simkiss D, Kamwendo F, Mhango C, Quenby S, Kandala NB, O'Hare JP. Up-skilling associate clinicians in Malawi in emergency obstetric, neonatal care and clinical leadership: the ETATMBA cluster randomised controlled trial. BMJ Glob Health 2017; 1:e000020. [PMID: 28588915 PMCID: PMC5321302 DOI: 10.1136/bmjgh-2015-000020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 11/08/2022] Open
Abstract
Background The ETATMBA (Enhancing Training And Technology for Mothers and Babies in Africa) project-trained associate clinicians (ACs/clinical officers) as advanced clinical leaders in emergency obstetric and neonatal care. This trial aimed to evaluate the impact of training on obstetric health outcomes in Malawi. Method A cluster randomised controlled trial with 14 districts of Malawi (8 intervention, 6 control) as units of randomisation. Intervention districts housed the 46 ACs who received the training programme. The primary outcome was district (health facility-based) perinatal mortality rates. Secondary outcomes included maternal mortality ratios, neonatal mortality rate, obstetric and birth variables. The study period was 2011–2013. Mortality rates/ratios were examined using an interrupted time series (ITS) to identify trends over time. Results The ITS reveals an improving trend in perinatal mortality across both groups, but better in the control group (intervention, effect −3.58, SE 2.65, CI (−9.85 to 2.69), p=0.20; control, effect −17.79, SE 6.83, CI (−33.95 to −1.64), p=0.03). Maternal mortality ratios are seen to have improved in intervention districts while worsening in the control districts (intervention, effect −38.11, SE 50.30, CI (−157.06 to 80.84), p=0.47; control, effect 11.55, SE 87.72, CI (−195.87 to 218.98), p=0.90). There was a 31% drop in neonatal mortality rate in intervention districts while in control districts, the rate rises by 2%. There are no significant differences in the other secondary outcomes. Conclusions This is one of the first randomised studies looking at the effect of structured training on health outcomes in this setting. Notwithstanding a number of limitations, this study suggests that up-skilling this cadre is possible, and could impact positively on health outcomes. Trial registration number ISRCTN63294155; Results.
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Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | | | - David Davies
- Educational Development & Research Team, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Doug Simkiss
- Division of Mental Health & Wellbeing, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Francis Kamwendo
- Obstetrics and Gynaecology Department, Malawi University, College of Medicine, Blantyre, Malawi
| | - Chisale Mhango
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Siobhan Quenby
- Division of Reproductive Health, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Ngianga-Bakwin Kandala
- Faculty of Engineering and Environment, Department of Mathematics and Information sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Joseph Paul O'Hare
- Division of Metabolic & Vascular Health, Warwick Medical School, The University of Warwick, Coventry, UK
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Sandhu H, Bernstein CJ, Davies G, Tang NKY, Belhag M, Tingle A, Field M, Foss J, Lindahl A, Underwood M, Ellard DR. Combined cognitive-behavioural and mindfulness programme for people living with dystonia: a proof-of-concept study. BMJ Open 2016; 6:e011495. [PMID: 27496234 PMCID: PMC4985914 DOI: 10.1136/bmjopen-2016-011495] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To design and test the delivery of an intervention targeting the non-motor symptoms of dystonia and pilot key health and well-being questionnaires in this population. DESIGN A proof-of-concept study to test the delivery, acceptability, relevance, structure and content for a 3-day group residential programme for the management of dystonia. SETTING Participants were recruited from a single botulinum toxin clinic. The intervention was delivered in the community. PARTICIPANTS 14 participants consented to take part (2 withdrew prior to the starting of intervention). The average age was 60 years (range 44-77), 8 of whom were female. After drop-out, 9 participants completed the 3-day programme. INTERVENTION A 3-day group residential programme. PRIMARY AND SECONDARY OUTCOME MEASURES Process evaluation and interviews were carried out before and after the intervention to explore participant's views and expectations, as well as experiences of the intervention. Select questionnaires were completed at baseline, 1-month and 3-month follow-up. RESULTS Although participants were not sure what to expect from the programme, they found it informative and for many this together with being in a group with other people with dystonia legitimised their condition. Mindfulness was accepted and adopted as a coping strategy. This was reflected in the 1-month follow-up. CONCLUSIONS We successfully delivered a 3-day residential programme to help those living with dystonia manage their condition. Further improvements are suggested. The quantitative outcome measures were acceptable to this group of patients with dystonia.
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Affiliation(s)
- H Sandhu
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - C J Bernstein
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - G Davies
- University of Southampton, Southampton, UK
| | - N K Y Tang
- Department of Psychology, University of Warwick, Coventry, UK
| | - M Belhag
- Department of Neurology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - A Tingle
- The Dystonia Society (West Midlands Group), West Midlands, UK
| | - M Field
- The Dystonia Society (West Midlands Group), West Midlands, UK
| | - J Foss
- Department of Computer Science, University of Warwick, Coventry, UK
| | - A Lindahl
- Department of Neurology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - M Underwood
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - D R Ellard
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Patel S, Hee SW, Mistry D, Jordan J, Brown S, Dritsaki M, Ellard DR, Friede T, Lamb SE, Lord J, Madan J, Morris T, Stallard N, Tysall C, Willis A, Underwood M. Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials. Programme Grants Appl Res 2016. [DOI: 10.3310/pgfar04100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundThere is good evidence that therapist-delivered interventions have modest beneficial effects for people with low back pain (LBP). Identification of subgroups of people with LBP who may benefit from these different treatment approaches is an important research priority.Aim and objectivesTo improve the clinical effectiveness and cost-effectiveness of LBP treatment by providing patients, their clinical advisors and health-service purchasers with better information about which participants are most likely to benefit from which treatment choices. Our objectives were to synthesise what is already known about the validity, reliability and predictive value of possible treatment moderators (patient factors that predict response to treatment) for therapist-delivered interventions; develop a repository of individual participant data from randomised controlled trials (RCTs) testing therapist-delivered interventions for LBP; determine which participant characteristics, if any, predict clinical response to different treatments for LBP; and determine which participant characteristics, if any, predict the most cost-effective treatments for LBP. Achieving these objectives required substantial methodological work, including the development and evaluation of some novel statistical approaches. This programme of work was not designed to analyse the main effect of interventions and no such interpretations should be made.MethodsFirst, we reviewed the literature on treatment moderators and subgroups. We initially invited investigators of trials of therapist-delivered interventions for LBP with > 179 participants to share their data with us; some further smaller trials that were offered to us were also included. Using these trials we developed a repository of individual participant data of therapist-delivered interventions for LBP. Using this data set we sought to identify which participant characteristics, if any, predict response to different treatments (moderators) for clinical effectiveness and cost-effectiveness outcomes. We undertook an analysis of covariance to identify potential moderators to apply in our main analyses. Subsequently, we developed and applied three methods of subgroup identification: recursive partitioning (interaction trees and subgroup identification based on a differential effect search); adaptive risk group refinement; and an individual participant data indirect network meta-analysis (NWMA) to identify subgroups defined by multiple parameters.ResultsWe included data from 19 RCTs with 9328 participants (mean age 49 years, 57% females). Our prespecified analyses using recursive partitioning and adaptive risk group refinement performed well and allowed us to identify some subgroups. The differences in the effect size in the different subgroups were typically small and unlikely to be clinically meaningful. Increasing baseline severity on the outcome of interest was the strongest driver of subgroup identification that we identified. Additionally, we explored the application of Bayesian indirect NWMA. This method produced varying probabilities that a particular treatment choice would be most likely to be effective for a specific patient profile.ConclusionsThese data lack clinical effectiveness or cost-effectiveness justification for the use of baseline characteristics in the development of subgroups for back pain. The methodological developments from this work have the potential to be applied in other clinical areas. The pooled repository database will serve as a valuable resource to the LBP research community.FundingThe National Institute for Health Research Programme Grants for Applied Research programme. This project benefited from facilities funded through Birmingham Science City Translational Medicine Clinical Research and Infrastructure Trials Platform, with support from Advantage West Midlands (AWM) and the Wolfson Foundation.
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Affiliation(s)
- Shilpa Patel
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Siew Wan Hee
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dipesh Mistry
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Jordan
- Brunel University, Health Economics Research Group, Uxbridge, UK
- Surrey Health Economic Centre, School of Economics, University of Surrey, Guildford, UK
| | - Sally Brown
- Universities/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - Melina Dritsaki
- Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David R Ellard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Centre Göttingen, Göttingen, Germany
| | - Sarah E Lamb
- Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanne Lord
- Brunel University, Health Economics Research Group, Uxbridge, UK
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Colin Tysall
- Universities/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - Adrian Willis
- Warwick Medical School, University of Warwick, Coventry, UK
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Bernstein CJ, Ellard DR, Davies G, Hertenstein E, Tang NKY, Underwood M, Sandhu H. Behavioural interventions for people living with adult-onset primary dystonia: a systematic review. BMC Neurol 2016; 16:40. [PMID: 27000094 PMCID: PMC4802601 DOI: 10.1186/s12883-016-0562-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 03/15/2016] [Indexed: 11/10/2022] Open
Abstract
Background Primary dystonia is a chronic neurological movement disorder that causes abnormal muscle movements. Pain and emotional distress may accompany these physical symptoms. Behavioural interventions are used to help people with long term conditions improve their quality of life. Little is known about behavioural interventions applied to Dystonia. We report a systematic review of studies reporting current evidence of behavioural interventions for people with primary dystonia. Methods We did systematic searches of Medline, PsycINFO, AHMED and CINAHL. We assessed the methodological quality of included studies using a risk of bias tool. Any disagreements were resolved by liaising with an independent rater. Physiological outcomes such as dystonia severity and psychological outcomes such as sleep and depression were selected on the basis that primary dystonia causes motor and non-motor symptoms. No time limit was placed on the searches. A narrative synthesis of the results is presented. Results Of 1798 titles and abstracts screened, 14 full articles were retrieved and inclusion and exclusion criteria applied. Of these a final nine were eligible for the review (N = 73). Only two were Randomised Controlled Trials (RCTs). Using the Movement Disorders Society (MDS) dystonia classification, that was published after this work started, all of the included studies were of idiopathic adult onset focal dystonia without associated features. These included: blepharospasm (eye dystonia) (N = 1), cervical dystonia (neck dystonia) (N = 2), writer’s cramp (hand dystonia) (N = 3) and the yips (N = 3). No studies reported on dystonia that affects two or more body regions. Studies reported good adherence and response rates to treatment. Physiological and psychological improvements were noted in all studies at weekly, monthly and yearly follow-ups. Caution should be taken when interpreting the results because of the scarcity of RCTs identified, use of small sample sizes, and inappropriate statistical methods. Conclusion We identified few studies; mainly of poor methodological quality that all studied a focal dystonia. It is not possible to draw firm conclusions. Nevertheless, the data suggests that a combined behavioural therapy approach including relaxation practice for people with idiopathic adult onset focal dystonia merits further investigation.
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Affiliation(s)
- C J Bernstein
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - D R Ellard
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.
| | - G Davies
- University of Southampton, Southampton, UK
| | - E Hertenstein
- Department of Psychiatry and Psychotherapy, University of Freiburg Medical Center, Freiburg, Germany
| | - N K Y Tang
- Department of Psychology, University of Warwick, Coventry, UK
| | - M Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - H Sandhu
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Ellard DR, Shemdoe A, Mazuguni F, Mbaruku G, Davies D, Kihaile P, Pemba S, Bergström S, Nyamtema A, Mohamed HM, O'Hare JP. Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project. BMJ Open 2016; 6:e008999. [PMID: 26873044 PMCID: PMC4762145 DOI: 10.1136/bmjopen-2015-008999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES During late 2010, 36 trainees including 19 assistant medical officers (AMOs) 1 senior clinical officer (CO) and 16 nurse midwives/nurses were recruited from districts across rural Tanzania and invited to join the Enhancing Human Resources and Use of Appropriate Technologies for Maternal and Perinatal Survival in the sub-Saharan Africa (ETATMBA) training programme. The ETATMBA project was training associate clinicians (ACs) as advanced clinical leaders in emergency obstetric care. The trainees returned to health facilities across the country with the hope of being able to apply their new skills and knowledge. The main aim of this study was to explore the impact of the ETATMBA training on health outcomes including maternal and neonatal morbidity and mortality in their facilities. Secondly, to explore the challenges faced in working in these health facilities. DESIGN The study is a pre-examination/postexamination of maternal and neonatal health indicators and a survey of health facilities in rural Tanzania. The facilities surveyed were those in which ETATMBA trainees were placed post-training. The maternal and neonatal indicators were collected for 2011 and 2013 and the survey of the facilities was in early 2014. RESULTS 16 of 17 facilities were surveyed. Maternal deaths show a non-significant downward trend over the 2 years (282-232 cases/100,000 live births). There were no significant differences in maternal, neonatal and birth complication variables across the time-points. The survey of facilities revealed shortages in key areas and some are a serious concern. CONCLUSIONS This study represents a snapshot of rural health facilities providing maternal and neonatal care in Tanzania. Enhancing knowledge, practical skills, and clinical leadership of ACs may have a positive impact on health outcomes. However, any impact may be confounded by the significant challenges in delivering a service in terms of resources. Thus, training may be beneficial, but it requires an infrastructure that supports it.
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Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | | | | | | | - David Davies
- Educational Development & Research Team, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Paul Kihaile
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Senga Pemba
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Staffan Bergström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Angelo Nyamtema
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | | | - Joseph Paul O'Hare
- Division of Metabolic and Vascular Health, Warwick Medical School, The University of Warwick, Coventry, UK
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Ellard DR, Shemdoe A, Mazuguni F, Mbaruku G, Davies D, Kihaile P, Pemba S, Bergström S, Nyamtema A, Mohamed HM, O'Hare JP. A qualitative process evaluation of training for non-physician clinicians/associate clinicians (NPCs/ACs) in emergency maternal, neonatal care and clinical leadership, impact on clinical services improvements in rural Tanzania: the ETATMBA project. BMJ Open 2016; 6:e009000. [PMID: 26873045 PMCID: PMC4762120 DOI: 10.1136/bmjopen-2015-009000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES The Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in sub-Saharan Africa (ETATMBA) project is training non-physician clinicians as advanced clinical leaders in emergency maternal and newborn care in Tanzania and Malawi. The main aims of this process evaluation were to explore the implementation of the programme of training in Tanzania, how it was received, how or if the training has been implemented into practice and the challenges faced along the way. DESIGN Qualitative interviews with trainees, trainers, district officers and others exploring the application of the training into practice. PARTICIPANTS During late 2010 and 2011, 36 trainees including 19 assistant medical officers one senior clinical officer and 16 nurse midwives/nurses (anaesthesia) were recruited from districts across rural Tanzania and invited to join the ETATMBA training programme. RESULTS Trainees (n=36) completed the training returning to 17 facilities, two left and one died shortly after training. Of the remaining trainees, 27 were interviewed at their health facility. Training was well received and knowledge and skills were increased. There were a number of challenges faced by trainees, not least that their new skills could not be practised because the facilities they returned to were not upgraded. Nonetheless, there is evidence that the training is having an effect locally on health outcomes, like maternal and neonatal mortality, and the trainees are sharing their new knowledge and skills with others. CONCLUSIONS The outcome of this evaluation is encouraging but highlights that there are many ongoing challenges relating to infrastructure (including appropriate facilities, electricity and water) and the availability of basic supplies and drugs. This cadre of workers is a dedicated and valuable resource that can make a difference, which with better support could make a greater contribution to healthcare in the country.
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Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | | | | | | | - David Davies
- Educational Development & Research Team, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Paul Kihaile
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Senga Pemba
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | - Staffan Bergström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Angelo Nyamtema
- Tanzanian Training Centre for International Health, Ifakara, Tanzania
| | | | - Joseph Paul O'Hare
- Division of Metabolic & Vascular Health, Warwick Medical School, The University of Warwick, Coventry, UK
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Sandhu H, Ellard DR, Achana F, Antrobus JHL, Balasubramanian S, Brown S, Cairns M, Griffiths F, Haywood K, Hutchinson C, Lall R, Petrou S, Stallard N, Tysall C, Walsh DA, Underwood M. Facet-joint injections for people with persistent non-specific low back pain (FIS): study protocol for a randomised controlled feasibility trial. Trials 2015; 16:588. [PMID: 26703477 PMCID: PMC4690389 DOI: 10.1186/s13063-015-1117-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/14/2015] [Indexed: 11/24/2022] Open
Abstract
Background The role of injections of therapeutic substances into the back as treatment for low back pain is unclear. Facet joint injections are widely used despite the absence of evidence of sustained benefit. We hypothesise that facet joint injections might facilitate engagement with physiotherapist-led, best usual care (a combined physical and psychological programme) and is a clinically and cost-effective treatment for people with suspected low back pain of facet joint origin. Methods/Design We present here the protocol for a randomised controlled feasibility trial for a main trial to test the above hypotheses. Patients referred to secondary care with persistent non-specific low back pain will be screened and invited to take part in the study. Those who meet the eligibility criteria will be invited for a physiotherapy assessment to confirm trial eligibility and for baseline data collection. All participants (n = 150) will be offered the best usual care package with physical and psychological components. Those randomised into the intervention arm (n = 75) will, in addition, receive intra-articular facet joint injections with local anaesthetic and steroids. Primary outcome data will be collected using daily and then weekly text messaging service for a pain score on a 0–10 scale. Questionnaire follow-up will be at 3, 6, and 12 months. Evaluation of trial processes and health economic analyses, including a value of information analysis, will be undertaken. The process evaluation will be mixed methods and will include the views of all stakeholders. Discussion Whilst this trial is a feasibility study it is currently one of the largest trials in this area. The outcomes will provide some evidence on the use of facet joint injections for patients with clinically diagnosed facet joint pain. Trial registration EudraCT identifier 2014-000682-50, (registered on 12 February 14). ISRCTN registry number: ISRCTN93184143 DOI 10.1186/ISRCTN93184143 (registered on 27 February 2014). Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1117-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harbinder Sandhu
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK.
| | - David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK.
| | - Felix Achana
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK.
| | - James H L Antrobus
- Anaesthesia & Pain Medicine, South Warwickshire NHS Foundation Trust, Warwick Hospital, Lakin Road, Warwick, CV34 5BW, UK.
| | - Shyam Balasubramanian
- Anaesthesia & Pain Services, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Sally Brown
- UNTRAP, The University of Warwick, Coventry, CV4 7AL, UK.
| | - Melinda Cairns
- Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK.
| | - Frances Griffiths
- Social Science and Systems in Health, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK.
| | - Kirstie Haywood
- RCN Research Institute, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK.
| | - Charles Hutchinson
- Population Evidence and Technologies Room, Warwick Medical School, The University of Warwick, University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK.
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK.
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, The University of Warwick, Coventry, CV4 7AL, UK.
| | - Colin Tysall
- UNTRAP, The University of Warwick, Coventry, CV4 7AL, UK.
| | - David A Walsh
- Arthritis Research UK Pain Centre, Academic Rheumatology, University of Nottingham, NG51PB, Nottingham, UK.
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK.
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Ellard DR. Intraarticular Facet Injections for Low Back Pain:
Design Considerations, Consensus Methodology
to Develop the Protocol for a Randomized
Controlled Trial. Pain Physician 2015. [DOI: 10.36076/ppj.2015/18/473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Since the publication of guidelines by the UK National Institute for Health and Care
Excellence (NICE) and the American Pain Society guidelines for low back pain in 2009 there have
been deep divisions in the pain treatment community about the use of therapeutic intraarticular
facet joint injections. While evidence for the effectiveness or not of intraarticular facet joint injections
remains sparse, uncertainty will remain. The Warwick feasibility study, along with a concurrent study
with a different design led by another group, aims to provide a stable platform from which the
effectiveness and cost effectiveness of intraarticular facet joint injections added to normal care could
be evaluated in randomized controlled trials (RCTs).
Objectives: To reach consensus on key design considerations for the Warwick facet feasibility
study from which the study protocol and working manuals will be developed.
Study Design: A consensus conference involving expert professionals and lay members.
Methods: Preliminary work identified 5 key design considerations for deliberation at our consensus
conference. Three concerned patient assessment and treatment: diagnosis of possible facet joint pain,
interaarticular facet joint injection technique, and best usual care. Two concerned trial analysis: a
priori sub-groups and minimally important difference and are reported elsewhere. We did systematic
evidence reviews of the design considerations and summarized the evidence. Our design questions
and evidence summaries were distributed to all delegates. This formed the basis for discussions on
the day. Clinical experts in all aspects of facet joint injection from across the UK along with lay people
were invited via relevant organizations. Nominal group technique was used in 15 facilitated initial
small group discussions. Further discussion and ranking was undertaken in plenary. All small group and
plenary results were recorded and checked and verified post conference. Where necessary participants
were contacted via email to resolve outstanding issues.
Results: Fifty-two delegates attended the conference with lay people and all relevant professions
represented. Consensus was reached on the details of how to assess patients for facet joint pain,
undertake the injections, and deliver usual care. Where post conference checking of results revealed
errors in calculating ranking results on the day, consensus was reached by email consultation. All but
3 delegates agreed to be associated with the outcome.
Limitations: Allocating one day for discussing a wide range of topics imposed time pressure on
discussion and calculation of the numerous rankings.
Conclusions: Through the use of an evidence-based, systematic, inclusive, and transparent process
we have established consensus from expert health professionals in the UK, with lay input, on the
clinical assessment of suspected facet joint pain, interaarticular injection for facet joint pain, and
best usual care for use in a feasibility study for a proposed pragmatic clinical trial of interaarticular
facet joint injections. This provides a strong basis for a clinical trial that will be acceptable to the pain
treatment community.
Key words: Low back pain, interaarticular facet joint injections, best usual care, consensus,
nominal group technique
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Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK
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Mars T, Ellard DR, Antrobus JHL, Cairns M, Underwood M, Haywood K, Keohane S, Sandhu H, Griffiths F. Intraarticular Facet Injections for Low Back Pain: Design Considerations, Consensus Methodology to Develop the Protocol for a Randomized Controlled Trial. Pain Physician 2015; 18:473-493. [PMID: 26431124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Since the publication of guidelines by the UK National Institute for Health and Care Excellence (NICE) and the American Pain Society guidelines for low back pain in 2009 there have been deep divisions in the pain treatment community about the use of therapeutic intraarticular facet joint injections. While evidence for the effectiveness or not of intraarticular facet joint injections remains sparse, uncertainty will remain. The Warwick feasibility study, along with a concurrent study with a different design led by another group, aims to provide a stable platform from which the effectiveness and cost effectiveness of intraarticular facet joint injections added to normal care could be evaluated in randomized controlled trials (RCTs). OBJECTIVES To reach consensus on key design considerations for the Warwick facet feasibility study from which the study protocol and working manuals will be developed. STUDY DESIGN A consensus conference involving expert professionals and lay members. METHODS Preliminary work identified 5 key design considerations for deliberation at our consensus conference. Three concerned patient assessment and treatment: diagnosis of possible facet joint pain, interaarticular facet joint injection technique, and best usual care. Two concerned trial analysis: a priori sub-groups and minimally important difference and are reported elsewhere. We did systematic evidence reviews of the design considerations and summarized the evidence. Our design questions and evidence summaries were distributed to all delegates. This formed the basis for discussions on the day. Clinical experts in all aspects of facet joint injection from across the UK along with lay people were invited via relevant organizations. Nominal group technique was used in 15 facilitated initial small group discussions. Further discussion and ranking was undertaken in plenary. All small group and plenary results were recorded and checked and verified post conference. Where necessary participants were contacted via email to resolve outstanding issues. RESULTS Fifty-two delegates attended the conference with lay people and all relevant professions represented. Consensus was reached on the details of how to assess patients for facet joint pain, undertake the injections, and deliver usual care. Where post conference checking of results revealed errors in calculating ranking results on the day, consensus was reached by email consultation. All but 3 delegates agreed to be associated with the outcome. LIMITATIONS Allocating one day for discussing a wide range of topics imposed time pressure on discussion and calculation of the numerous rankings. CONCLUSIONS Through the use of an evidence-based, systematic, inclusive, and transparent process we have established consensus from expert health professionals in the UK, with lay input, on the clinical assessment of suspected facet joint pain, interaarticular injection for facet joint pain, and best usual care for use in a feasibility study for a proposed pragmatic clinical trial of interaarticular facet joint injections. This provides a strong basis for a clinical trial that will be acceptable to the pain treatment community.
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Affiliation(s)
- Tom Mars
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK
| | - James H L Antrobus
- Anaesthesia & Pain Medicine, South Warwickshire NHS Foundation Trust, Warwick Hospital, Lakin Road, Warwick, CV34 5BW, UK
| | - Melinda Cairns
- Department of Allied Health Professions and Midwifery, School of Health and Social Work
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK
| | - Kirstie Haywood
- RCN Research Institute, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK
| | - Susie Keohane
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK
| | - Harbinder Sandhu
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK
| | - Frances Griffiths
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK
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Gurung T, Ellard DR, Mistry D, Patel S, Underwood M. Identifying potential moderators for response to treatment in low back pain: A systematic review. Physiotherapy 2015; 101:243-51. [PMID: 25769189 DOI: 10.1016/j.physio.2015.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 01/17/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Identifying which patients with non-specific low back pain are likely to gain the greatest benefit from different treatments is an important research priority. Few studies are large enough to produce data on sub-group effects from different treatments. Data from existing large studies may help identify potential moderators to use in future individual patient data meta-analyses. OBJECTIVE To systematically review papers of therapist delivered interventions for low back pain to identify potential moderators to inform an individual patient data meta-analysis. DATA SOURCES We searched MEDLINE, EMBASE, Web of Science and Citation Index and Cochrane Register of Controlled Trials (CENTRALhttp://www.cochrane.org/editorial-and-publishing-policy-resource/cochrane-central-register-controlled-trials-central) for relevant papers. DATA EXTRACTION AND DATA SYNTHESIS We screened for randomised controlled trials with ≥500 or more participants, and cohort studies of ≥1000 or more participants. We examined all publications related to these studies for any reported moderator analyses. Two reviewers independently did risk of bias assessment of main results and quality assessment of any moderator analyses. RESULTS We included four randomised trials (n=7208). Potential moderators with strong evidence (p<0.05) in one or more studies were age, employment status and type, back pain status, narcotic medication use, treatment expectations and education. Potential moderators with weaker evidence (0.05<p≤0.20) included gender, psychological distress, pain/disability and quality of life. CONCLUSION There are insufficient robust data on moderators to be useful in clinical practice. This review has identified some important potential moderators of treatment effect worthy of testing in future confirmatory analyses.
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Affiliation(s)
- Tara Gurung
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
| | - David R Ellard
- Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
| | - Dipesh Mistry
- Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
| | - Shilpa Patel
- Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
| | - Martin Underwood
- Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
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Ellard DR, Chimwaza W, Davies D, O'Hare JP, Kamwendo F, Quenby S, Griffiths F. Can training in advanced clinical skills in obstetrics, neonatal care and leadership, of non-physician clinicians in Malawi impact on clinical services improvements (the ETATMBA project): a process evaluation. BMJ Open 2014; 4:e005751. [PMID: 25116455 PMCID: PMC4139632 DOI: 10.1136/bmjopen-2014-005751] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES The 'enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa' (ETATMBA) project is training emergency obstetric and new-born care (EmONC) non-physician clinicians (NPCs) as advanced clinical leaders. Our objectives were to evaluate the implementation and changes to practice. DESIGN A mixed methods process evaluation with the predominate methodology being qualitative. SETTING Rural and urban hospitals in 8 of the 14 districts of northern and central Malawi. PARTICIPANTS 54 EmONC NPCs with 3 years' plus experience. INTERVENTION Training designed and delivered by clinicians from the UK and Malawi; it is a 2-year plus package of training (classroom, mentorship and assignments). RESULTS We conducted 79 trainee interviews over three time points during the training, as well as a convenience sample of 10 colleagues, 7 district officers and 2 UK obstetricians. Trainees worked in a context of substantial variation in the rates of maternal and neonatal deaths between districts. Training reached trainees working across the target regions. For 46 trainees (8 dropped out of the course), dose delivered in terms of attendance was high and all 46 spent time working alongside an obstetrician. In early interviews trainees recalled course content unprompted indicating training had been received. Colleagues and district officers reported cascading of knowledge and initial changes in practice indicating early implementation. By asking trainees to describe actual cases we found they had implemented new knowledge and skills. These included life-saving interventions for postpartum haemorrhage and eclampsia. Trainees identified the leadership training as enabling them to confidently change their own practice and initiate change in their health facility. CONCLUSIONS This process evaluation suggests that trainees have made positive changes in their practice. Clear impacts on maternal and perinatal mortality are yet to be elucidated.
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Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | | | - David Davies
- Educational Development & Research Team, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Joseph Paul O'Hare
- Division of Metabolic & Vascular Health, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Francis Kamwendo
- Obstetrics and Gynaecology Department, Malawi University, College of Medicine, Blantyre, Malawi
| | - Siobhan Quenby
- Division of Reproductive Health, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
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Underwood M, Lamb SE, Eldridge S, Sheehan B, Slowther A, Spencer A, Thorogood M, Atherton N, Bremner SA, Devine A, Diaz-Ordaz K, Ellard DR, Potter R, Spanjers K, Taylor SJC. Exercise for depression in care home residents: a randomised controlled trial with cost-effectiveness analysis (OPERA). Health Technol Assess 2014; 17:1-281. [PMID: 23632142 DOI: 10.3310/hta17180] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many older people living in care homes (long term residential care or nursing homes) are depressed. Exercise is a promising non-drug intervention for preventing and treating depression in this population. OBJECTIVE To evaluate the impact of a 'whole-home' intervention, consisting of training for residential and nursing home staff backed up with a twice-weekly, physiotherapist-led exercise class on depressive symptoms in care home residents. DESIGN A cluster randomised controlled trial with a cost-effectiveness analysis to compare (1) the prevalence of depression in intervention homes with that in control homes in all residents contributing data 12 months after homes were randomised (cross-sectional analysis); (2) the number of depressive symptoms at 6 months between intervention and control homes in residents who were depressed at pre-randomisation baseline assessment (depressed cohort comparison); and (3) the number of depressive symptoms at 12 months between intervention and control homes in all residents who were present at pre-randomisation baseline assessment (cohort comparison). SETTING Seventy-eight care homes in Coventry and Warwickshire and north-east London. PARTICIPANTS Care home residents aged ≥ 65 years. INTERVENTIONS Control intervention: Depression awareness training programme for care home staff. Active intervention: A 'whole-home' exercise intervention, consisting of training for care home staff backed up with a twice-weekly, physiotherapist-led exercise group. MAIN OUTCOME MEASURES Geriatric Depression Scale-15, proxy European Quality of Life-5 Dimensions (EQ-5D), cost-effectiveness from an National Health Service perspective, peripheral fractures and death. RESULTS We recruited a total of 1054 participants. Cross-sectional analysis: We obtained 595 Geriatric Depression Scale-15 scores and 724 proxy EQ-5D scores. For the cohort analyses we obtained 765 baseline Geriatric Depression Scale-15 scores and 776 proxy EQ-5D scores. Of the 781 who we assessed prior to randomisation, 765 provided a Geriatric Depression Scale-15 score. Of these 374 (49%) were depressed and constitute our depressed cohort. Resource-use and quality-adjusted life-year data, based on proxy EQ-5D, were available for 798 residents recruited prior to randomisation. We delivered 3191 group exercise sessions with 31,705 person attendances and an average group size of 10 (5.3 study participants and 4.6 non-study participants). On average, our participants attended around half of the possible sessions. No serious adverse events occurred during the group exercise sessions. In the cross-sectional analysis the odds for being depressed were 0.76 [95% confidence interval (CI) 0.53 to 1.09] lower in the intervention group at 12 months. The point estimates for benefit for both the cohort analysis (0.13, 95% CI -0.33 to 0.60) and depressed cohort (0.22, 95% CI -0.52 to 0.95) favoured the control intervention. There was no evidence of differences in fracture rates or mortality (odds ratio 1.07, 95% CI 0.79 to 1.48) between the two groups. There was no evidence of differences in the other outcomes between the two groups. Economic analysis: The additional National Health Service cost of the OPERA intervention was £374 per participant (95% CI -£655 to £1404); the mean difference in quality-adjusted life-year was -0.0014 (95% CI -0.0728 to 0.0699). The active intervention was thus dominated by the control intervention, which was more effective and less costly. CONCLUSION The results do not support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in care home residents. TRIAL REGISTRATION Current Controlled Trials ISRCTN43769277. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 18. See the Health Technology Assessment programme website for further project information.
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Affiliation(s)
- M Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Ellard DR, Thorogood M, Underwood M, Seale C, Taylor SJC. Whole home exercise intervention for depression in older care home residents (the OPERA study): a process evaluation. BMC Med 2014; 12:1. [PMID: 24386900 PMCID: PMC3882778 DOI: 10.1186/1741-7015-12-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 12/06/2013] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The 'Older People's Exercise intervention in Residential and nursing Accommodation' (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect. METHODS The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known. RESULTS Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises. CONCLUSIONS The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms.
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Affiliation(s)
- David R Ellard
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK.
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Underwood M, Lamb S, Sheehan B, Ellard DR, Taylor SJ. Exercise for depression in elderly people - Authors' reply. Lancet 2013; 382:1325. [PMID: 24139113 DOI: 10.1016/s0140-6736(13)62132-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Underwood M, Lamb SE, Eldridge S, Sheehan B, Slowther AM, Spencer A, Thorogood M, Atherton N, Bremner SA, Devine A, Diaz-Ordaz K, Ellard DR, Potter R, Spanjers K, Taylor SJC. Exercise for depression in elderly residents of care homes: a cluster-randomised controlled trial. Lancet 2013; 382:41-9. [PMID: 23643112 PMCID: PMC3919159 DOI: 10.1016/s0140-6736(13)60649-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Depression is common and is associated with poor outcomes among elderly care-home residents. Exercise is a promising low-risk intervention for depression in this population. We tested the hypothesis that a moderate intensity exercise programme would reduce the burden of depressive symptoms in residents of care homes. METHODS We did a cluster-randomised controlled trial in care homes in two regions in England; northeast London, and Coventry and Warwickshire. Residents aged 65 years or older were eligible for inclusion. A statistician independent of the study randomised each home (1 to 1·5 ratio, stratified by location, minimised by type of home provider [local authority, voluntary, private and care home, private and nursing home] and size of home [<32 or ≥32 residents]) into intervention and control groups. The intervention package included depression awareness training for care-home staff, 45 min physiotherapist-led group exercise sessions for residents (delivered twice weekly), and a whole home component designed to encourage more physical activity in daily life. The control consisted of only the depression awareness training. Researchers collecting follow-up data from individual participants and the participants themselves were inevitably aware of home randomisation because of the physiotherapists' activities within the home. A researcher masked to study allocation coded NHS routine data. The primary outcome was number of depressive symptoms on the geriatric depression scale-15 (GDS-15). Follow-up was for 12 months. This trial is registered with ISRCTN Register, number ISRCTN43769277. FINDINGS Care homes were randomised between Dec 15, 2008, and April 9, 2010. At randomisation, 891 individuals in 78 care homes (35 intervention, 43 control) had provided baseline data. We delivered 3191 group exercise sessions attended on average by five study participants and five non-study residents. Of residents with a GDS-15 score, 374 of 765 (49%) were depressed at baseline; 484 of 765 (63%) provided 12 month follow-up scores. Overall the GDS-15 score was 0·13 (95% CI -0·33 to 0·60) points higher (worse) at 12 months for the intervention group compared with the control group. Among residents depressed at baseline, GDS-15 score was 0·22 (95% CI -0·52 to 0·95) points higher at 6 months in the intervention group than in the control group. In an end of study cross-sectional analysis, including 132 additional residents joining after randomisation, the odds of being depressed were 0·76 (95% CI 0·53 to 1·09) for the intervention group compared with the control group. INTERPRETATION This moderately intense exercise programme did not reduce depressive symptoms in residents of care homes. In this frail population, alternative strategies to manage psychological symptoms are required. FUNDING National Institute for Health Research Health Technology Assessment.
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Affiliation(s)
- Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry, UK.
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Ellard DR, Taylor SJC, Parsons S, Thorogood M. The OPERA trial: a protocol for the process evaluation of a randomised trial of an exercise intervention for older people in residential and nursing accommodation. Trials 2011; 12:28. [PMID: 21288341 PMCID: PMC3037884 DOI: 10.1186/1745-6215-12-28] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 02/02/2011] [Indexed: 11/15/2022] Open
Abstract
Background The OPERA trial is large cluster randomised trial testing a physical activity intervention to address depression amongst people living in nursing and residential homes for older people. A process evaluation was commissioned alongside the trial and we report the protocol for this process evaluation. Challenges included the cognitive and physical ability of the participants, the need to respect the privacy of all home residents, including study non-participants, and the physical structure of the homes. Evaluation activity had to be organised around the structured timetable of homes, leaving limited opportunities for data collection. The aims of this process evaluation are to provide findings that will assist in the interpretation of the clinical trial results, and to inform potential implementation of the physical activity intervention on a wider scale. Methods/design Quantitative data on recruitment of homes and individuals is being collected. For homes in the intervention arm, data on dose and fidelity of the intervention delivered; including individual rates of participation in exercise classes are collected. In the control homes, uptake and delivery of depression awareness training is monitored. These data will be combined with qualitative data from an in-depth study of a purposive sample of eight homes (six intervention and two control). Discussion Although process evaluations are increasingly funded alongside trials, it is still rare to see the findings published, and even rarer to see the protocol for such an evaluation published. Process evaluations have the potential to assist in interpreting and understanding trial results as well as informing future roll-outs of interventions. If such evaluations are funded they should also be reported and reviewed in a similar way to the trial outcome evaluation. Trial Registration ISRCTN No: ISRCTN43769277
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Affiliation(s)
- David R Ellard
- University of Warwick, Clinical Trials Unit, Warwick Medical School, Gibbet Hill Road, Coventry, CV4 7AL, UK.
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Ellard DR, Barlow JH, Paskins Z, Stapley J, Wild A, Rowe IF. Piloting education days for patients with early rheumatoid arthritis and their partners: a multidisciplinary approach. Musculoskeletal Care 2009; 7:17-30. [PMID: 18688791 DOI: 10.1002/msc.137] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To develop, pilot, refine and reassess an education day presented by a rheumatology multidisciplinary team (MDT) for recently diagnosed (less than six months) rheumatoid arthritis (RA) patients and their partners/carers. METHODS A patient education day was developed drawing on an assessment of local patient educational needs and preferences and input from a rheumatology MDT. Feedback from the first education day (2004) (Day 1; 12 patients; age range 19-63 years (median 46); 10 of whom were accompanied by a partner) informed the development of a second education day (2005) (Day 2; 19 patients; age range 36-75 years (median 57.5); 13 of whom were accompanied by a partner). Participants completed evaluation forms on both days and at follow-up between six and seven weeks later, rating each session on a 5-point scale on dimensions of 'informative', 'useful', 'interesting' and 'enjoyable'. A global rating of the day's 'usefulness' was completed at the end of each day on a 10-point scale. Participants were asked to write comments on each session and on aspects of the entire day. RA knowledge, and general and RA-specific self-efficacy were also measured on day 2 (and at follow-up) using the 12-item Patient Knowledge Questionnaire, the 10-item generalized self-efficacy scale and a four-item RA-specific self-efficacy scale. Both qualitative and quantitative methodologies were used in the analysis. RESULTS Ratings for individual sessions were all high, with no session being rated below 4 out of 5 (1 = 'totally disagree' to 5 = 'totally agree') on both days. The majority of patients (84%) and their partners (57%) responded to the follow-up. Many had used the information package distributed on the day. Some patients and their partners reported positive changes in RA management. Although patient knowledge did not increase significantly (medians 11 at both time points, p = 0.054) (Day 2), RA self-efficacy improved (baseline 11 and 14, respectively), suggesting that patients were more confident in managing their condition (p = 0.010). CONCLUSIONS The development of this 'local' education and information intervention was carried out in line with Medical Research Council guidelines, and the lessons learned from Day 1 informed further development for Day 2. A one-day format for education of early RA involving the rheumatology MDT was rated highly by participants and warrants further examination. Although this study was a small 'local' intervention, its strengths are that it informs the possibility of wider developments of this kind using a MDT.
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Affiliation(s)
- D R Ellard
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
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Barlow JH, Stapley J, Ellard DR. Living with haemophilia and von Willebrand's: a descriptive qualitative study. Patient Educ Couns 2007; 68:235-42. [PMID: 17904328 DOI: 10.1016/j.pec.2007.06.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 06/08/2007] [Accepted: 06/12/2007] [Indexed: 05/17/2023]
Abstract
OBJECTIVE The aim of this qualitative descriptive study was to describe the experience of living with bleeding disorders and to identify the associated salient issues from the perspectives of people living with haemophilia or von Willebrand's Disease (vWD). METHODS Nine members of The Haemophilia Society took part in a semi-structured interview. The interviews were tape recorded and transcribed and the results subjected to thematic content analysis. RESULTS Participants described the physical aspects of their condition, such as bleeding into joints, the implications of bleeds and development of co-morbid conditions (e.g. arthritis). Many felt that their bleeding disorder had impacted on their education, work, social activities and family life. Anxiety and depression were associated with daily management of symptoms, the unpredictable nature of bleeding disorders and concerns about the future. All participants had encountered a degree of stigmatisation related to their condition and felt that there was a public misconception about bleeding disorders. Many had experienced discrimination in educational and work settings. Some participants expressed a preference for seeking treatment from specialist services. CONCLUSION Living with haemophilia and vWD poses a number of daily and longer-term challenges not only for individuals, but also for their families. Further investigation of ways to support such individuals is warranted. PRACTICE IMPLICATIONS Greater awareness and understanding of the issues faced by people living with haemophilia and vWD is needed for the general public, employers, and healthcare staff, particularly those working in Accident and Emergency Departments.
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Affiliation(s)
- Julie H Barlow
- Self-Management Programme, Applied Research Centre in Health & Lifestyle Interventions, Faculty of Health & Life Sciences, Coventry University, Priory Street, Coventry CV1 5FB, UK
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Abstract
The aim of the study was to conduct a survey of information and self-management needs among members of the UK Haemophilia Society (HS). Of 1082 members mailed, 307 took part in the survey, the mean age was 52.4 years (SD 14.8), 85% were male, 96% white and 66% were living with haemophilia A. 90% felt that there is a lack of understanding amongst the public regarding bleeding disorders, 76% felt that health professionals understood their health and information needs and 32% had experienced problems managing anxiety and or depression. Results suggest that there was a 'stigma' attached to having a bleeding disorder and almost half are very careful about informing others that they have a bleeding disorder. Self-efficacy was relatively high within the sample. Many respondents wanted to be kept informed about current research and the opportunity to participate in research. Women experienced a greater need for more information than men, particularly in the area of the 'medical management' and 'emotional' topics. Men appeared to need more information and or training on 'physical' aspects such as physiotherapy and joint replacement. The study provides an insight into the educational and self-management needs of those affected by bleeding disorders and highlights the importance of providing accessible information.
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Affiliation(s)
- J H Barlow
- Applied Research Centre in Health and Lifestyle Interventions, Coventry University, Coventry, UK
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