Exploring the issues that influence how people with rare neurological conditions engage in physical activity

PURPOSE

People with rare neurological conditions (RNCs) struggle to achieve regular physical activity (PA). This study explored experiences of people with RNC engaging in PA, their carers, and health care professionals (HCPs) working with them.

MATERIALS & METHODS

We developed three surveys: for individuals living with RNCs, their carers, and HCPs working with them. Themes from interviews with RNC charity representatives were used to co-design questions, together with people living with RNCs, their representatives, and an expert panel. Surveys were disseminated via charity mailing lists, social media accounts, and professional networks (HCPs).

RESULTS

We received 436 responses (225 people with RNC, 94 carers, 117 HCPs). Most respondents with RNC achieved some level of regular PA but needed motivation to maintain it. Many felt they lacked knowledge on starting and staying active, with scarce resources and support. Most HCP respondents worked in specialist services, and overwhelmingly agreed that people with RNC should be physically active, while acknowledging lack of evidence and resources.

CONCLUSIONS

We identified key barriers at environmental/organisational, interpersonal, and intrapersonal levels, highlighting a critical lack of support for people with RNC across UK health services. These factors can be targeted to increase engagement in PA.Implications for rehabilitationPeople living with rare neurological conditions experience barriers to engaging in physical activity, with some common to more prevalent neurological diseases, e.g. access and facilities, but some notable differences due to the rarity of the conditionFor people living with rare neurological conditions, and their carers, there is a lack of knowledge on safe and appropriate engagement in physical activityIncreasing the knowledge of health and exercise professionals may improve how they support people with rare neurological disease to engage with physical activity.Evidence based resources and recommendations for people living with rare neurological conditions, and professionals working with them, may facilitate engagement in physical activity.

An updated audit of the patient selection process for pain management programmes in a speciality care service before and during the COVID-19 pandemic

BACKGROUND

The provision of pain management programmes (PMPs) changed substantially in response to the COVID-19 pandemic with virtual delivery implemented in many services. Little is known about patient selection processes for virtual PMPs and how this might differ from in-person programmes. The aim of this audit was to document the patient selection process for PMPs at a speciality pain service prior to and during the pandemic.

METHODS

This retrospective audit used data from consecutive patients attending a multidisciplinary assessment to determine the suitability of a PMP. Anonymized data were extracted from assessment letters and hospital records in the months prior to the pandemic (n =168) and during the start of the pandemic once the service began delivering virtual PMPs (n =171).

RESULTS

For the standard pain management pathway, most patients were offered a PMP option within the service before and during the pandemic, although a greater proportion of patients were offered treatment during the pandemic. For the neuromodulation pathway, most patients were offered a pre-neuromodulation PMP option, and this was similar before and during the pandemic. Psychosocial complexities and unwillingness to engage in a pain management approach that does not principally focus on pain reduction were the most common reasons that patients were not offered a programme.

DISCUSSION

This audit points to a pattern of more inclusive assessment outcomes within our service over time and particularly during the pandemic. Offering a range of in-person and virtual PMPs can meet a wider range of patient need. Research is needed to understand how to best assess and match patients with the breadth of treatment delivery formats now available.

Proposing a Core Outcome Set for Physical Activity and Exercise Interventions in People With Rare Neurological Conditions

Rare neurological conditions (RNCs) encompass a variety of diseases that differ in progression and symptoms but typically include muscle weakness, sensory and balance impairment and difficulty with coordinating voluntary movement. This can limit overall physical activity, so interventions to address this are recommended. The aim of this study was to agree a core outcome measurement set for physical activity interventions in people living with RNCs. We followed established guidelines to develop core outcome sets. Broad ranging discussions in a series of stakeholder workshops led to the consensus that (1) physical well-being; (2) psychological well-being and (3) participation in day-to-day activities should be evaluated in interventions. Recommendations were further informed by a scoping review of physical activity interventions for people living with RNCs. Nearly 200 outcome measures were identified from the review with a specific focus on activities or functions (e.g, on lower limb function, ability to perform daily tasks) but limited consideration of participation based outcomes (e.g., social interaction, work and leisure). Follow on searches identified two instruments that matched the priority areas: the Oxford Participation and Activities Questionnaire and the Sources of Self-Efficacy for Physical Activity. We propose these scales as measures to assess outcomes that are particularly relevant to assess when evaluating physical activity interventions mong people with RNCs. Validation work across rare neurological conditions is now required to inform application of this core outcome set in future clinical trials to facilitate syntheses of results and meta-analyses.

Low Somatosensory Cortex Excitability in the Acute Stage of Low Back Pain Causes Chronic Pain

Determining the mechanistic causes of complex biopsychosocial health conditions such as low back pain (LBP) is challenging, and research is scarce. Cross-sectional studies demonstrate altered excitability and organization of the somatosensory and motor cortex in people with acute and chronic LBP, however, no study has explored these mechanisms longitudinally or attempted to draw causal inferences. Using sensory evoked potential area measurements and transcranial magnetic stimulation derived map volume we analyzed somatosensory and motor cortex excitability in 120 adults experiencing acute LBP. Following multivariable regression modelling with adjustment for confounding, we identified lower primary (OR = 2.08, 95% CI = 1.22-3.57) and secondary (OR = 2.56, 95% CI = 1.37-4.76) somatosensory cortex excitability significantly increased the odds of developing chronic pain at 6-month follow-up. Corticomotor excitability in the acute stage of LBP was associated with higher pain intensity at 6-month follow-up (B = -0.15, 95% CI: -0.28 to -0.02) but this association did not remain after confounder adjustment. These data provide evidence that low somatosensory cortex excitability in the acute stage of LBP is a cause of chronic pain. PERSPECTIVE: This prospective longitudinal cohort study design identified low sensorimotor cortex excitability during the acute stage of LBP in people who developed chronic pain. Interventions that target this proposed mechanism may be relevant to the prevention of chronic pain.

Major hepatectomy for perihilar cholangiocarcinoma in elderly patients: is it reasonable?

Introduction

We sought to evaluate the effect of age on postoperative outcomes among patients undergoing major liver surgery for perihilar cholangiocarcinoma (PHCC).

Methods

77 patients were included. Patients were categorized into two groups: the “< 70-year-olds” group (n = 54) and the “≥ 70-year-olds” group (n = 23).

Results

Median LOS was 19 both for < 70-year-old group and ≥ 70-year-old group (P = 0.72). No differences in terms of severe complication were detected (44.4% Clavien–Dindo 3–4–5 in < 70-year-old group vs 47.8% in ≥ 70-year-old group, P = 0.60). Within 90 postoperative days, 11 patients died, 6 in < 70-year-old group (11.3%) and 5 in ≥ 70-year-old group (21.7%), P = 0.29. The median follow‐up was 20 months. The death rate was 72.2% and 78.3% among patients < 70 years old and ≥ 70 years old. The OS at 2 and 5 years was significantly higher among the < 70 years old (57.0% and 27.7%) compared to the ≥ 70 years old (27.1% and 13.6%), P = 0.043. Adjusting for hypertension and Charlson comorbidity index in a multivariate analysis, the HR for age was 1.93 (95% CI 0.84–4.44), P = 0.12. Relapse occurred in 43 (81.1%) patients in the < 70-year-old group and in 19 (82.6%) patients in the ≥ 70-year-old group. DFS at 12, 24, and 36 months was, respectively, 59.6, 34.2, and 23.2 for the < 70 -year-old group and 32.5, 20.3, and 13.5 for the ≥ 70-year-old group (P = 0.26). Adjusting for hypertension and Charlson comorbidity index in a Cox model, the HR for age was 1.52 (95% CI 0.67–3.46), with P = 0.32.

Conclusions

 ≥ 70-year-old patients with PHCC can still be eligible for major liver resection with acceptable complication rates and should not be precluded a priori from a radical treatment.

Is there a causal relationship between acute stage sensorimotor cortex activity and the development of chronic low back pain? a protocol and statistical analysis plan

INTRODUCTION

Why some people develop chronic pain following an acute episode of low back pain is unknown. Recent cross-sectional studies have suggested a relationship between aberrant sensorimotor cortex activity and pain persistence. The UPWaRD (Understanding persistent Pain Where it ResiDes) cohort study is the first prospective, longitudinal investigation of sensorimotor cortex activity in low back pain. This paper describes the development of a causal model and statistical analysis plan for investigating the causal effect of sensorimotor cortex activity on the development of chronic low back pain.

METHODS AND ANALYSIS

Sensorimotor cortex activity was assessed within 6 weeks of low back pain onset using somatosensory evoked potentials and transcranial magnetic stimulation mapping techniques. Chronic low back pain is defined as ongoing pain (Numerical Rating score ≥1) or disability (Roland Morris Disability Questionnaire score ≥3) at 6 months follow-up. Variables that could confound the relationship between sensorimotor cortex activity and chronic low back pain were identified using a directed acyclic graph and content expertise was used to specify known causal paths. The statistical model was developed 'a priori' to control for confounding variables identified in the directed acyclic graph, allowing an unbiased estimate of the causal effect of sensorimotor activity in acute low back pain on the development of chronic pain. The statistical analysis plan was finalised prior to follow-up of all participants and initiation of analysis.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Western Sydney University Human Research Ethics Committee (H10465) and from Neuroscience Research Australia (SSA: 16/002). Dissemination will occur through presentations at national and international conferences and publications in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12619000002189 (retrospectively registered).

Do sensorimotor cortex activity, an individual's capacity for neuroplasticity, and psychological features during an episode of acute low back pain predict outcome at 6 months: a protocol for an Australian, multisite prospective, longitudinal cohort study

INTRODUCTION

Low back pain (LBP) is the leading cause of disability worldwide, with prevalence doubling in the past 14 years. To date, prognostic screening tools display poor discrimination and offer no net benefit of screening over and above a 'treat all' approach. Characteristics of the primary sensory (S1) and motor (M1) cortices may predict the development of chronic LBP, yet the prognostic potential of these variables remains unknown. The Understanding persistent Pain Where it ResiDes (UPWaRD) study aims to determine whether sensorimotor cortex activity, an individual's capacity for plasticity and psychosocial factors in the acute stage of pain, predict LBP outcome at 6 months. This paper describes the methods and analysis plan for the development of the prediction model.

METHODS AND ANALYSIS

The study uses a multicentre prospective longitudinal cohort design with 6-month follow-up. 120 participants, aged 18 years or older, experiencing an acute episode of LBP (less than 6 weeks duration) will be included. Primary outcomes are pain and disability.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Western Sydney University Human Research Ethics Committee (H10465) and from Neuroscience Research Australia (SSA: 16/002). Dissemination will occur through presentations at national and international conferences and publications in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12619000002189; Pre-results.

Sensorimotor Cortical Activity in Acute Low Back Pain: A Cross-Sectional Study

Sensorimotor cortical activity is altered in both the immediate acute and chronic stages of musculoskeletal pain. However, these changes are opposite, with decreased cortical activity reported in experimentally induced acute pain (lasting minutes to hours), and increased cortical activity in chronic, clinical pain (lasting >6 months). It is unknown whether sensorimotor cortical activity is altered in acute, clinical musculoskeletal pain (lasting <4 weeks). In 36 individuals with acute, nonspecific, clinical low back pain (LBP) and 36 age- and sex-matched, pain-free controls, we investigated the processing of non-noxious afferent inputs using sensory evoked potentials (SEPs), as well as corticomotor excitability and organization of the primary motor cortex using transcranial magnetic stimulation. Processing of non-noxious sensory inputs was lower (smaller area of the N₈₀-N₁₅₀-P₂₆₀ SEP complex) in acute LBP (F_1,70 = 45.28, P < .01). The examination of specific SEP components revealed a smaller area of the N₁₅₀ and P₂₆₀ SEP components in acute LBP, although interindividual variability was high. Motor cortical map volume was lower in acute LBP (F_1,70 = 5.61, P = .02). These findings demonstrate that acute LBP is characterized by lower sensorimotor cortical activity at the group level. However, individual variation was high, suggesting individual adaptation of cortical plasticity in acute pain. PERSPECTIVE: This is the first study to examine sensorimotor cortical activity in the acute stage of clinical LBP. This information is critical for understanding the neurophysiology of acute LBP.

The role of psychosocial stress in the development of chronic musculoskeletal pain disorders: protocol for a systematic review and meta-analysis

BACKGROUND

Psychosocial factors play an important role in chronic musculoskeletal pain disorders. Although psychosocial stress is likely to contribute to the development of chronic musculoskeletal pain, investigations are limited to work-related stress or examination of specific conditions such as upper limb pain. The purpose of this review is to assess the evidence for an aetiological role of psychological stress in chronic musculoskeletal pain disorders.

METHODS

A systematic review and meta-analysis will be conducted. Electronic databases will be searched using predefined search terms to identify relevant studies. Data will be extracted by two independent reviewers, and disagreement will be resolved by a third reviewer. Only prospective longitudinal studies that assess psychosocial stress at baseline will be included. The population of interest will be inception cohorts or cohorts of people who have not yet developed chronic musculoskeletal pain disorders. The primary outcome measure will be the onset of chronic musculoskeletal pain.

DISCUSSION

To our knowledge, this review will be the first to systematically explore the available evidence on the aetiological role of psychosocial stress for the development of chronic musculoskeletal pain disorders. This review has the capacity to inform clinical practice on the importance of an early identification and, consequently, treatment of individuals who present with acute musculoskeletal disorders accompanied by a high level of stress.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017059949.

Do Older Liver Grafts Have Worse Survival? The Niguarda Experience

BACKGROUND

Elderly donor livers are thought to be marginal graft. In the present study, we aimed to identify an age threshold to consider a graft as elderly to identify the trend (if any) of the donor age in our series and to identify an efficient allocation criteria for elderly grafts.

METHODS

We reviewed in a retrospective manner our series of 1520 liver transplants, comparing graft survival under and over a certain age. On the basis of the results of this analysis, we identified a threshold of 70 years to define a graft as old. The donor age trend analysis showed an increasing rate of transplants from elderly donors.

RESULTS

To identify efficient allocation criteria for elderly graft, we stratified the series by the disease of the recipient: 556 patients underwent transplants for hepatocellular carcinoma (HCC+ group) and 964 for other diseases (HCC- group). Two hundred twenty-one patients of 556 of the HCC+ group were hepatitis c virus (HCV) negative (HCC+/HCV- group), and 312 of 964 of the HCC- group were HCV positive (HCC-/HCV+). The survival analysis showed no significant differences in comparing the outcome for elderly and young grafts in the HCC+ (P = .135) and HCC- (P = .055) groups.

CONCLUSIONS

When comparing the survival of old and young livers in the HCC+/HCV- group, the elderly livers appear to have a better outcome (P = .05); on the other hand, the same analysis in the HCC-/HCV+ group shows a worse outcome for old-aged grafts (P = .026). Therefore, the present study suggests that elderly livers should be allocated to hepatocellular carcinoma (HCC) patients and should be avoided in HCV+ recipients.

A qualitative exploration of living with chronic neuropathic pain after spinal cord injury: an Italian perspective

PURPOSE

The purpose of this study is to understand how people with spinal cord injury (SCI) in Italy experienced and managed chronic neuropathic pain (CNP), and their perspectives of Italian healthcare services.

METHOD

Nine people with SCI participated. Two focus groups (three and four individuals) and one semi-structured interview were audio-recorded and transcribed. One "virtual interview" was conducted via e-mail. A qualitative thematic analysis was undertaken.

RESULTS

Three main themes were identified. First, participants experienced pain as a powerful, intrusive and, at times, inescapable force, with the potential to overwhelm the sense of self, and place limits on enjoyable experiences. Second, participants recounted a strong desire to understand CNP, and, in the absence of expert guidance, used trial-and-error methods to find ways of relieving pain. Third, healthcare practice was perceived as pharmacologically focused and lacking specialist knowledge. Practitioners were described as reluctant to explore alternative therapies or participate in collaborative, patient-centred care.

CONCLUSIONS

This study reveals SCI-related CNP as a deeply troubling and psychologically distressing condition impacting widely on everyday life. Specialist, collaborative, individually tailored rehabilitation approaches that attend to patients' priorities and experiences, include education about CNP, and offer opportunities to explore complementary treatments, may be welcomed by people living with this condition in Italy. Implications for Rehabilitation People living in Italy with SCI-related CNP describe inadequate and ineffective pain relief. The impact of CNP on physical, psychological and social functioning is significant but may be an issue that continues to be underestimated by health professionals. Health professionals may better support patients living in Italy with SCI-related CNP by providing long-term, individualized, collaborative and specialist support. Ongoing, patient-led discussion forums where experiences, ideas and information can be shared may be useful to persons with SCI to help them cope with their pain over the long-term.