The voice and swallowing profile of adults with laryngotracheal stenosis before and after reconstructive surgery: A prospective, descriptive observational study

OBJECTIVES

Airway reconstruction for laryngo tracheal stenosis (LTS) improves dyspnoea. There is little evidence relating to impact upon voice and swallowing. We explored voice and swallowing outcomes in adults with LTS before and after reconstructive surgery.

DESIGN

Outcome measures were collected pre-reconstructive surgery, two-weeks post-surgery and up to 4-6 months post-surgery.

SETTING

Tertiary referral centre.

PARTICIPANTS

With ethical approval, twenty consecutive adult (≥18 years) LTS patients undergoing airway reconstruction were prospectively recruited.

MAIN OUTCOME MEASURES

These included physiological values (maximum phonation time (MPT) and fundamental frequency; penetration aspiration score, residue score), clinician-reported (GRBAS, functional oral intake score, 100ml Water Swallow Test) and patient-reported outcomes (Voice Handicap Index-10, Reflux Symptoms Index, Eating Assessment Tool, Dysphagia Handicap Index).

RESULTS

The observational study identified patient-reported and clinician-reported voice and swallow difficulties pre- and post-surgery; median and interquartile range are reported at each time point: Voice Handicap Index-10 23 (8-31); 20.5 (9-33.5), 24.5 (12.5-29); Dysphagia Handicap Index 9 (0-37); 13 (7-44); 15 (4-34); GRBAS grade 1(1-2); 2 (1-2.5); 2(1-2); 100ml Water Swallow Test volume score 16.7 (11.1-20); 14.3 (12.5-16.7); 16.7 (14.3-20.0); 100ml Water Swallow Test capacity score 16.3 ± 9.0; 11.0 ± 4.1; 12.5 ± 2.6.

CONCLUSIONS

We present the first prospective data on voice and swallowing outcomes in adults with LTS before and after reconstructive surgery. The variability of the outcomes was higher than expected but importantly, for many the voice and swallow outcomes were not within normal limits before surgery. The clinical value of the study demonstrates the need for individual assessment and management of LTS patients' voice and swallowing.

mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis

BACKGROUND

With the rapid development of mobile health (mHealth) technology, many health apps have been introduced to the commercial market for people with back pain conditions. However, little is known about their content, quality, approaches to care for low back pain (LBP), and associated risks of use.

OBJECTIVE

The aims of this research were to (1) identify apps for the self-management of LBP currently on the market and (2) assess their quality, intervention content, theoretical approaches, and risk-related approaches.

METHODS

The UK iTunes and Google Play stores were initially searched for apps related to the self-management of LBP in May 2022. A repeat search in June 2023 was conducted to ensure that any relevant new apps developed in the last year were incorporated into the review. A total of 3 keywords recommended by the Cochrane Back and Neck Group were used to search apps "low back pain," "back pain," and "lumbago." The quality of the apps was assessed by using the 5-point Mobile App Rating Scale (MARS).

RESULTS

A total of 69 apps (25 iOS and 44 Android) met the inclusion criteria. These LBP self-management apps mainly provide recommendations on muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), core stability exercises (n=32, 46.4%), yoga (n=19, 27.5%), and information about LBP mechanisms (n=17, 24.6%). Most interventions (n=14, 78%) are consistent with the recommendations in the National Institute for Health and Care Excellence (NICE) guidelines. The mean (SD) MARS overall score of included apps was 2.4 (0.44) out of a possible 5 points. The functionality dimension was associated with the highest score (3.0), whereas the engagement and information dimension resulted in the lowest score (2.1). Regarding theoretical and risk-related approaches, 18 (26.1%) of the 69 apps reported the rate of intervention progression, 11 (15.9%) reported safety checks, only 1 (1.4%) reported personalization of care, and none reported the theoretical care model or the age group targeted.

CONCLUSIONS

mHealth apps are potentially promising alternatives to help people manage their LBP; however, most of the LBP self-management apps were of poor quality and did not report the theoretical approaches to care and their associated risks. Although nearly all apps reviewed included a component of care listed in the NICE guidelines, the model of care delivery or embracement of care principles such as the application of a biopsychosocial model was unclear.

Physiotherapists' perceptions on using a multidimensional clinical reasoning form during psychologically informed training for low back pain

PURPOSE

Building clinical reasoning skills is important to effectively implement psychologically informed practice. We developed a multidimensional clinical reasoning form (CRF) to be used by physiotherapists in a psychologically informed practice training programme for low back pain. In this paper we describe the development of the CRF, how the CRF was used in the training, and present an evaluation of physiotherapists' perceptions of the CRF.

METHODS

Qualitative semi-structured interviews were conducted with ten physiotherapists purposively sampled in primary care. Data were gathered through pre, and post training focus group interviews and a secondary analysis of individual physiotherapist interviews conducted after the training. Thematic analysis was used to analyse the data and capture the emergent themes.

RESULTS

Two main themes emerged before the training: (1) the CRF 'needs formal training' and (2) 'lacked instruction'. Three main themes emerged after the training (1) it provided 'a helpful framework for multidimensional clinical reasoning' (2) the CRF, and accompanying operational definitions, helped physiotherapists 'elicit information, with 'question prompts' helpful in facilitating patient disclosure (3) 'Utility' - although the CRF was not formally used by the physiotherapists it provided a conceptual reasoning framework to work from with more challenging patients.

CONCLUSION

The CRF was not designed to be used in isolation by clinicians without training. However, when used as a training adjunct it appears to be valued by physiotherapists to help develop their critical thinking and better characterise patients' presentations in order to personalise care from a bio-psychosocial perspective.

Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial

BACKGROUND

Low back pain is the leading cause of years lived with disability globally, but most interventions have only short-lasting, small to moderate effects. Cognitive functional therapy (CFT) is an individualised approach that targets unhelpful pain-related cognitions, emotions, and behaviours that contribute to pain and disability. Movement sensor biofeedback might enhance treatment effects. We aimed to compare the effectiveness and economic efficiency of CFT, delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling low back pain.

METHODS

RESTORE was a randomised, controlled, three-arm, parallel group, phase 3 trial, done in 20 primary care physiotherapy clinics in Australia. We recruited adults (aged ≥18 years) with low back pain lasting more than 3 months with at least moderate pain-related physical activity limitation. Exclusion criteria were serious spinal pathology (eg, fracture, infection, or cancer), any medical condition that prevented being physically active, being pregnant or having given birth within the previous 3 months, inadequate English literacy for the study's questionnaires and instructions, a skin allergy to hypoallergenic tape adhesives, surgery scheduled within 3 months, or an unwillingness to travel to trial sites. Participants were randomly assigned (1:1:1) via a centralised adaptive schedule to usual care, CFT only, or CFT plus biofeedback. The primary clinical outcome was activity limitation at 13 weeks, self-reported by participants using the 24-point Roland Morris Disability Questionnaire. The primary economic outcome was quality-adjusted life-years (QALYs). Participants in both interventions received up to seven treatment sessions over 12 weeks plus a booster session at 26 weeks. Physiotherapists and patients were not masked. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001396213.

FINDINGS

Between Oct 23, 2018 and Aug 3, 2020, we assessed 1011 patients for eligibility. After excluding 519 (51·3%) ineligible patients, we randomly assigned 492 (48·7%) participants; 164 (33%) to CFT only, 163 (33%) to CFT plus biofeedback, and 165 (34%) to usual care. Both interventions were more effective than usual care (CFT only mean difference -4·6 [95% CI -5·9 to -3·4] and CFT plus biofeedback mean difference -4·6 [-5·8 to -3·3]) for activity limitation at 13 weeks (primary endpoint). Effect sizes were similar at 52 weeks. Both interventions were also more effective than usual care for QALYs, and much less costly in terms of societal costs (direct and indirect costs and productivity losses; -AU$5276 [-10 529 to -24) and -8211 (-12 923 to -3500).

INTERPRETATION

CFT can produce large and sustained improvements for people with chronic disabling low back pain at considerably lower societal cost than that of usual care.

FUNDING

Australian National Health and Medical Research Council and Curtin University.

Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article II): a meta-analysis relating methods to trial results

ABSTRACT

Sham interventions in randomized clinical trials (RCTs) of physical, psychological, and self-management (PPS) therapies for pain are highly variable in design and believed to contribute to poor internal validity. However, it has not been formally tested whether the extent to which sham controls resemble the treatment under investigation consistently affects trial outcomes, such as effect sizes, differential attrition, participant expectancy, and blinding effectiveness. Placebo- or sham-controlled RCTs of PPS interventions of clinical pain populations were searched in 12 databases. The similarity of control interventions to the experimental treatment was rated across 25 features. Meta-regression analyses assessed putative links between employed control interventions, observed effect sizes in pain-related outcomes, attrition, and blinding success. The sample included 198 unique control interventions, dominated by manual therapy and chronic musculoskeletal pain research. Meta-analyses indicated small-to-moderate benefits of active treatments over control interventions, across subgroups of manual therapies, exercise, and rehabilitation, and psychological intervention trials. Multiple meta-regression modelling demonstrated that similarity between sham control and tested interventions predicted variability in pain-related outcomes, attrition, and blinding effectiveness. Influential variables were differences relating to the extent of intervention exposure, participant experience, and treatment environments. The results support the supposed link between blinding methods and effect sizes, based on a large and systematically sourced overview of methods. However, challenges to effective blinding are complex and often difficult to discern from trial reports. Nonetheless, these insights have the potential to change trial design, conduct, and reporting and will inform guideline development.

Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article I): a systematic review and description of methods

ABSTRACT

Blinding is challenging in randomised controlled trials of physical, psychological, and self-management therapies for pain, mainly because of their complex and participatory nature. To develop standards for the design, implementation, and reporting of control interventions in efficacy and mechanistic trials, a systematic overview of currently used sham interventions and other blinding methods was required. Twelve databases were searched for placebo or sham-controlled randomised clinical trials of physical, psychological, and self-management treatments in a clinical pain population. Screening and data extraction were performed in duplicate, and trial features, description of control methods, and their similarity to the active intervention under investigation were extracted (protocol registration ID: CRD42020206590). The review included 198 unique control interventions, published between 2008 and December 2021. Most trials studied people with chronic pain, and more than half were manual therapy trials. The described control interventions ranged from clearly modelled based on the active treatment to largely dissimilar control interventions. Similarity between control and active interventions was more frequent for certain aspects (eg, duration and frequency of treatments) than others (eg, physical treatment procedures and patient sensory experiences). We also provide an overview of additional, potentially useful methods to enhance blinding, as well as the reporting of processes involved in developing control interventions. A comprehensive picture of prevalent blinding methods is provided, including a detailed assessment of the resemblance between active and control interventions. These findings can inform future developments of control interventions in efficacy and mechanistic trials and best-practice recommendations.

'Is there something wrong with your voice?' A qualitative study of the voice concerns of people with laryngotracheal stenosis

BACKGROUND

Acquired laryngotracheal stenosis (LTS) is a rare condition that causes breathlessness and dyspnoea. Patients have reconstructive airway surgery to improve their breathing difficulties, but both LTS and the surgery can cause voice difficulties. The existing evidence base for management of voice difficulties for adults with LTS focuses on symptoms. There is limited information to provide clinical guidance for speech and language therapists (SLTs) and a limited understanding of the impact of voice changes on adults with LTS.

AIM

To investigate the lived experience of adults with laryngotracheal stenosis (LTS), who have had reconstructive surgery; here focussing on voice concerns with the aim of guiding clinical care for SLTs.

METHODS AND PROCEDURES

A phenomenological, qualitative study design was used. Focus groups and semi-structured interviews were completed with adults living with LTS who had had reconstructive surgery. Audio recordings were transcribed and inductive thematic analysis was used by the research team to identify themes and sub-themes.

OUTCOMES AND RESULTS

A total of 24 participants (five focus groups and two interviews) took part in the study before thematic saturation was identified in analysis. Three main themes were identified specific to the experience of living with LTS: the Medical, Physical and Emotional journey. All participants referenced voice difficulties as they related to each of these overall themes. Sub-themes directly related to voice included experience of surgery, information provision, staff expertise/complacency, symptoms, symptom management, identity, support networks, impact on life and living with a chronic condition.

CONCLUSIONS AND IMPLICATIONS

In this qualitative study participants have described the integral part voice difficulties play in their lived experience of LTS and reconstructive surgery. This is considered in the context of their clinical care and the need for individualised management and information provision throughout the course of their condition. The broader research literature relating to voice difficulties is explored with links made to people with LTS and recommendations made for future research into people living with LTS and dysphonia.

WHAT THIS PAPER ADDS

What is already known on this subject Adults with laryngotracheal stenosis (LTS) experience voice changes as a result of their condition, and the surgeries necessary as a treatment. These changes can lead to altered pitch, vocal fatigue, loss of pitch range and loss of volume control. Although there are known psychosocial implications both to living with a chronic condition and voice difficulties there has been no research exploring this in adults with LTS, and there is minimal clinical guidance for speech and language therapists (SLTs) working with these patients. What this paper adds to existing knowledge This research is the first study to explore the lived experience of adults with LTS who undergo reconstructive surgery, focusing on their voice concerns. This study demonstrates the multifactorial impacts of voice changes on all aspects of the lives of adults with LTS and the need for individualised information provision and clinical care to help support them. What are the potential or actual clinical implications of this work? Adults with LTS want expert SLTs to facilitate their care and support them throughout their LTS journey alongside other support networks. They want to be carefully prepared for reconstructive surgery and given clear information about symptoms and management of their voice difficulties. This has led to the reorganisation of the care pathway at our centre, and the introduction of a patient-led pretreatment session.

Diabetes mellitus is not a predictor of poor TB treatment outcomes

OBJECTIVE: To investigate whether diabetes mellitus (DM) influences TB treatment outcomes.METHODS: This was a retrospective observational cohort study of all notified TB cases from a large London TB centre over a 5-year period. WHO criteria were used to define TB treatment outcomes.RESULTS: The prevalence of DM at TB treatment initiation was 15% (126/838). Most patients (83.3%, 105/126) were on hypoglycaemic treatment and well-controlled (median glycated haemoglobin 53.5 mmol/mol). DM patients were older, more likely to be of Asian ethnicity and had a higher pre-treatment weight. Time from presentation to treatment initiation was longer (median 87.5 vs. 63 days; P < 0.001), while they were significantly more comorbid (median Charlson Comorbidity Index 3 vs. 0; P < 0.001). Overall, favourable treatment outcomes were recorded for 89.5% of patients (87.7% vs. 89.8% for DM and non-DM patients respectively, P = 0.52). In multivariable analysis, DM was not associated with unfavourable TB treatment outcomes (OR 0.49, 95% CI 0.23-1.04, P = 0.06). Independent predictors of unfavourable outcome included age, cavitation, chronic neurological disease and malignant neoplasm.CONCLUSIONS: In a well-resourced setting, with predominantly well-controlled DM patients on treatment, DM was not an independent predictor of unfavourable TB treatment outcomes.

Mapping Lower-Limb Prosthesis Load Distributions Using a Low-Cost Pressure Measurement System

Background

In the UK 55,000 people live with a major limb amputation. The prosthetic socket is problematic for users in relation to comfort and acceptance of the prosthesis; and is associated with the development of cysts and sores.

Objectives

We have developed a prototype low-cost system combining low-profile pressure sensitive sensors with an inertial measurement unit to assess loading distribution within prosthetic sockets. The objective of this study was to determine the ability of this prototype to assess in-socket loading profiles of a person with an amputation during walking, with a view to understanding socket design and fit.

Methods

The device was evaluated on four transtibial participants of various age and activity levels. The pressure sensors were embedded in the subject's sockets and an inertial measurement unit was attached to the posterior side of the socket. Measurements were taken during level walking in a gait lab.

Results

The sensors were able to dynamically collect data, informing loading profiles within the socket which were in line with expected distributions for patellar-tendon-bearing and total-surface-bearing sockets. The patellar tendon bearing subject displayed loading predominately at the patellar tendon, tibial and lateral gastrocnemius regions. The total-surface bearing subjects indicated even load distribution throughout the socket except in one participant who presented with a large socket-foot misalignment.

Conclusions

The sensors provided objective data showing the pressure distributions inside the prosthetic socket. The sensors were able to measure the pressure in the socket with sufficient accuracy to distinguish pressure regions that matched expected loading patterns. The information may be useful to aid fitting of complex residual limbs and for those with reduced sensation in their residual limb, alongside the subjective feedback from prosthesis users.

A qualitative evaluation of participants experiences of living with back pain, lumbar fusion surgery, and post-operative rehabilitation

Background

The use of lumbar fusion surgery is increasing in developed economies. High levels of patient dissatisfaction are reported post-operatively. To address this need, we developed a theoretically informed rehabilitation programme for use following lumbar fusion surgery (the REFS programme). We conducted a mixed methods randomised controlled feasibility study (REFS v ‘usual care’). The numerical and feasibility outcomes are reported separately. The current qualitative study was ‘nested’ within the main feasibility study to explore participants’ experiences before and after lumbar fusion surgery including the impact of rehabilitation content. This facilitated a deeper understanding of potential mechanisms of action, for theoretical and programme refinement.

Methods

A purposive sample (n = 10 ‘usual care’, n = 10 REFS) was identified from the main feasibility study cohort. Individual semi-structured interviews were conducted post-operatively (median 8 months, range 5–11). Interview data were transcribed verbatim, coded, and analysed thematically.

Results

Three themes were constructed: the breadth and severity of impact associated with a chronic lumbar disorder was summarised in theme 1, ‘Ever-decreasing circles; living with a chronic lumbar disorder’. Theme 2, ‘What have I done? Reflections on recovery from lumbar fusion surgery’, illustrated participants post-operative helplessness, which was associated with worsening mental health, problematic use of opioids, fear related to the instillation of metalware, and the important mitigating effect of informal social support. Theme 3 ‘Rehabilitation experiences’ identified critical rehabilitation programme content including exercise, a shared rehabilitation experience, the opportunity for vicarious learning, and professional expertise.

Conclusions

To enhance patient benefit future REFS programme iterations should consider reinforcement of the identified valued programme content. Additional content should be considered to mitigate post-operative fear, which frequently aligned with the instillation of metalware into the spine. Participant’s perceptions regarding the necessity of lumbar fusion surgery has potential implications for the surgical consent process.

Trial registration

Study registration; ISRCTN60891364, date registered 10/7/2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01050-y.

Not as simple as "fear of the unknown": A qualitative study exploring anxiety in the radiotherapy department

OBJECTIVE

Little is understood about the anxiety experienced by cancer patients undergoing radiotherapy or investigative imaging. Our aim was to identify sources of anxiety, the points along the cancer journey where anxiety occurred and methods to alleviate it.

METHODS

Six focus groups were conducted with cancer patients (n = 17), caregivers (n = 3) and healthcare practitioners (HCPs; n = 10) in the radiotherapy department. Patients described specific elements in the care pathway which induced anxiety, while HCPs focused on their perception of the patient experience. Thematic analysis was used to analyse data.

RESULTS

Three broad themes emerged: The Environment, The Individual and The Unknown. The physical environment of the hospital, inside the scanner for example, emerged as a key source of anxiety. The impact of cancer on patients' individual lives was significant, with many feeling isolated. The majority of participants described anxiety associated with the unknown. HCPs reported difficulty in identifying the anxious patient.

CONCLUSIONS

Anxiety is experienced throughout the cancer pathway. Common sources include the physical environment and the uncertainty associated with having cancer. Identifying both anxiety-inducing factors, and the anxious patients themselves, is crucial to enable targeted interventions to alleviate anxiety.

Assessment of changes in chest wall mechanics in esophageal cancer survivors using a 3D-motion capture system

TPS360

Background: Surgical resection remains the mainstay of treatment for loco-regional esophageal cancer. Traditional open esophagectomy is associated with considerable morbidity, with postoperative pulmonary complications (PPC) being the most frequently observed morbidity. There are several peri- and postoperative factors that are known to affect the respiratory mechanics, including an open surgical approach, administration of sedatives, rib spreading with subsequent fracture or nerve injury, presence of PPC and neuropathic pain leading to post-thoracotomy syndrome. Enhanced recovery programmes with early mobilization protocols and chest physiotherapy have been shown to reduce pulmonary complication rates. However, no data is currently available regarding the long-term respiratory function, quality of life and chest wall function in esophageal cancer survivors. Quantification of chest wall movements provides an objective measurement of function for the long term assessment of chest wall mechanics and could be used to develop tailored physiotherapy for patients undergoing esophagectomy. The aim of this study is to develop a method to objectively quantify changes in breathing mechanics in esophageal cancer survivors using a biomechanical approach. Methods: In the initial phase, an 89-marker protocol will be validated against a 3D-printed chest wall model that can produced simulate of normal and abnormal motions. Retroreflective markers will be placed non-invasively on the anterior, posterior, and lateral parts of the thorax and abdomen. A working protocol of breathing mechanics will be assessed in healthy control volunteers with the subject seated in upright position. Subjects will perform the respiratory function tests, the spirometer and the respiratory pressure meter. Further to this clinical assessment, the impact of thoracic movements and treadmill exercise will be assessed on the parameters obtained from changes in breathing movements. Following this, an optimization phase will refine markers placement and identify parameters that are most likely to be clinically relevant in the assessment of breathing mechanics. A finalized protocol will be trialled in esophageal cancer survivors, to identify changes in thoracoabdominal motion after surgery and to assess whether these changes are associated with impairment in health-related quality of life. This information will aid the development of evidenced based physiotherapy regimens tailored to the needs of this patient population. Clinical trial information: NCT03835273.

P-OGC46 Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-analysis

Background

Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPC), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. This meta-analysis aims to assess the impact of physiotherapy regimens following esophagectomy or gastrectomy.

Methods

An electronic database search was performed in MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPC and postoperative morbidity, in-hospital mortality rate, the Length of Hospital Stay (LOS) and the Health-Related Quality of Life (HRQoL).

Results

Seven RCTs and 7 cohort studies assessing prehabilitation totalling 960 patients, and 5 RCTs and 5 cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien-Dindo score &gt;II). No difference was observed in functional exercise capacity, and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, a shorter LOS and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue and pain scores.

Conclusions

Our meta-analysis shows that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative period. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which subgroup of patients will gain the most benefit.

Association between hip joint impingement and lumbar disc disease in elite rowers

Objectives

Lumbar disc disease is a known cause of back pain. Increasingly it is thought that cam morphology of the hip may have a causal role in development of lumbar disc disease. The aim of this study was to describe the morphology of the hip and investigate the association of cam morphology with lumbar disc disease observed on MRI in elite rowers.

Methods

Cross-sectional observational study of 20 elite rowers (12 male, 8 female, mean age 24.45, SD 2.1). Assessment included clinical examination, questionnaires, 3T MRI scans of the hips and lumbar spine. Alpha angle of the hips and Pfirrmann score of lumbar discs were measured.

Results

85% of rowers had a cam morphology in at least one hip. Alpha angle was greatest at the 1 o’clock position ((bone 70.9 (SD 16.9), cartilage 71.4 (16.3)). 95% of the group were noted to have labral tears, but only 50% of the group had history of groin pain. 85% of rowers had at least one disc with a Pfirrmann score of 3 or more and 95% had a history of back pain. A positive correlation was observed between the alpha angle and radiological degenerative disc disease (correlation coefficient=3.13, p=0.012). A negative correlation was observed between hip joint internal rotation and radiological degenerative disc disease (correlation coefficient=−2.60, p=0.018).

Conclusions

Rowers have a high prevalence of labral tears, cam morphology and lumbar disc disease. There is a possible association between cam morphology and radiological lumbar degenerative disc disease, however, further investigation is required.

Physiotherapists' Approaches to Patients' Concerns in Back Pain Consultations Following a Psychologically Informed Training Program

Guidelines advocate a combined physical and psychological approach to managing non-specific chronic low back pain (NSCLBP), referred to as psychologically informed practice (PIP). PIP is underpinned by patient-centered principles and skilled communication. Evidence suggests that a physiotherapist-focused style of communication prevails in physiotherapy. There is a recognized need for observational research to identify specific communication practices in physiotherapy interactions. This observational study explored the interactional negotiation of agenda setting following a PIP training intervention, by identifying and describing how physiotherapists solicit and respond to the agenda of concerns that patients with NSCLBP bring to primary care initial encounters. The research setting was primary care. Nineteen initial physiotherapy consultations were video-recorded, transcribed, and analyzed using conversation analysis, a qualitative observational method. These data revealed a patient-focused style of communication where trained physiotherapists demonstrated a collaborative and responsive style of verbal and nonverbal communication to solicit, explore, and validate patients' concerns.

Improving consultations for persistent musculoskeletal low back pain in orthopaedic spine settings: an intervention development

BACKGROUND

There is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking.

AIM

To develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial.

METHOD

The intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention.

RESULTS

In total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians' communication skills, during the consultation, in reference to listening skills, validation of patients' pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients' clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management.

CONCLUSION

The intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients' perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians.

"A Major Quality of Life Issue": A Survey-Based Analysis of the Experiences of Adults With Laryngotracheal Stenosis with Mucus and Cough

Objectives:

To investigate how the symptoms of mucus and cough impact adults living with laryngotracheal stenosis, and to use this information to guide future research and treatment plans.

Methods:

A survey was developed with the support of patient advisors and distributed to people suffering with laryngotracheal stenosis. The survey comprised 15 closed and open questions relating to mucus and cough and included the Leicester Cough Questionnaire (LCQ). Descriptive statistics, X² and thematic analyses were completed.

Results:

In total, 641 participants completed the survey, with 83.62% (n = 536) reporting problems with mucus; 79% having daily issues of varying severity that led to difficulties with cough (46.18%) and breathing (20.90%). Mucus affected voice and swallowing to a lesser degree. Respondents described a range of triggers; they identified smoky air as the worst environmental trigger. Strategies to manage mucus varied widely with drinking water (72.26%), increasing liquid intake in general (49.35%) and avoiding or reducing dairy (45.32%) the most common approaches to control symptoms. The LCQ showed a median total score of 14 (interquartile range 11-17) indicative of cough negatively affecting quality of life. Thematic analysis of free text responses identified 4 key themes—the Mucus Cycle, Social impact, Psychological impact, and Physical impact.

Conclusion:

This study shows the relevance of research focusing on mucus and cough and its negative impact on quality of life, among adults with laryngotracheal stenosis. It demonstrates the inconsistent advice and management strategies provided by clinicians for this issue. Further research is required to identify clearer treatment options and pathways.

Quantification of Motor Function Post-Stroke Using Novel Combination of Wearable Inertial and Mechanomyographic Sensors

Subjective clinical rating scales represent the gold-standard for diagnosis of motor function following stroke. In practice however, they suffer from well-recognized limitations including assessor variance, low inter-rater reliability and low resolution. Automated systems have been proposed for empirical quantification but have not significantly impacted clinical practice. We address translational challenges in this arena through: (1) implementation of a novel sensor suite combining inertial measurement and mechanomyography (MMG) to quantify hand and wrist motor function; and (2) introduction of a new range of signal features extracted from the suite to supplement predicted clinical scores. The wearable sensors, signal features, and machine learning algorithms have been combined to produce classified ratings from the Fugl-Meyer clinical assessment rating scale. Furthermore, we have designed the system to augment clinical rating with several sensor-derived supplementary features encompassing critical aspects of motor dysfunction (e.g. joint angle, muscle activity, etc.). Performance is validated through a large-scale study on a post-stroke cohort of 64 patients. Fugl-Meyer Assessment tasks were classified with 75% accuracy for gross motor tasks and 62% for hand/wrist motor tasks. Of greater import, supplementary features demonstrated concurrent validity with Fugl-Meyer ratings, evidencing their utility as new measures of motor function suited to automated assessment. Finally, the supplementary features also provide continuous measures of sub-components of motor function, offering the potential to complement low accuracy but well-validated clinical rating scales when high-quality motor outcome measures are required. We believe this work provides a basis for widespread clinical adoption of inertial-MMG sensor use for post-stroke clinical motor assessment.

2021 consensus statement for preventing and managing low back pain in elite and subelite adult rowers

PURPOSE

To synthesise evidence on low back pain (LBP) in adult rowers and to create a consensus statement to inform clinical practice.

METHODS

There were four synthesis steps that informed the consensus statement. In step one, seven expert clinicians and researchers established the scope of the consensus statement and conducted a survey of experienced and expert clinicians to explore current practice. In step two, working groups examined current evidence relating to key scope questions and summarised key issues. In step three, we synthesised evidence for each group and used a modified Delphi process to aid in the creation of the overall consensus statements. Finally, in step four, we combined information from step three with the findings of the clinician survey (and with athlete and coach input) to produce recommendations for clinical practice.

RESULTS

The scope of the consensus statement included epidemiology; biomechanics; management; the athlete's voice and clinical expertise. Prevention and management of LBP in rowers should include education on risk factors, rowing biomechanics and training load. If treatment is needed, non-invasive management, including early unloading from aggravating activities, effective pain control and exercise therapy should be considered. Fitness should be maintained with load management and progression to full training and competition. The role of surgery is unclear. Management should be athlete focused and a culture of openness within the team encouraged.

CONCLUSION

Recommendations are based on current evidence and consensus and aligned with international LBP guidelines in non-athletic populations, but with advice aimed specifically at rowers. We recommend that research in relation to all aspects of prevention and management of LBP in rowers be intensified.

Adaptation of balance reactions following forward perturbations in people with joint hypermobility syndrome

BACKGROUND

Joint Hypermobility Syndrome (JHS) is a Heritable Disorder of Connective tissue characterised by joint laxity and chronic widespread arthralgia. People with JHS exhibit a range of other symptoms including balance problems. To explore balance further, the objective of this study is to compare responses to forward perturbations between three groups; people who are hypermobile with (JHS) and without symptoms and people with normal flexibility.

METHODS

Twenty-one participants with JHS, 23 participants with Generalised Joint Hypermobility (GJH) and 22 participants who have normal flexibility (NF) stood on a platform that performed 6 sequential, sudden forward perturbations (the platform moved to the anterior to the participant). Electromyographic outcomes (EMG) and kinematics for the lower limbs were recorded using a Vicon motion capture system. Within and between group comparisons were made using Kruskal Wallis tests.

RESULTS

There were no significant differences between groups in muscle onset latency. At the 1st perturbation the group with JHS had significantly longer time-to-peak amplitude than the NF group in tibialis anterior, vastus medialis, rectus femoris, vastus lateralis, and than the GJH group in the gluteus medius. The JHS group showed significantly higher cumulative joint angle (CA) than the NF group in the hip and knee at the 1st and 2nd and 6th perturbation, and in the ankle at the 2nd perturbation. Participants with JHS had significantly higher CA than the GJH group at the in the hip and knee in the 1st and 2nd perturbation. There were no significant differences in TTR.

CONCLUSIONS

The JHS group were able to normalise the timing of their muscular response in relation to control groups. They were less able to normalise joint CA, which may be indicative of impaired balance control and strength, resulting in reduced stability.

The relationship between rowing-related low back pain and rowing biomechanics: a systematic review

BACKGROUND

Low back pain (LBP) is common in rowers. Understanding rowing biomechanics may help facilitate prevention and improve rehabilitation.

OBJECTIVES

To define the kinematics and muscle activity of rowers and to compare with rowers with current or LBP history.

DESIGN

Systematic review.

DATA SOURCES

EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Scopus from inception to December 2019. Grey literature was searched.

STUDY ELIGIBILITY CRITERIA

Experimental and non-experimental designs.

METHODS

Primary outcomes were kinematics and muscle activity. Modified Quality Index (QI) checklist was used.

RESULTS

22 studies were included (429 participants). Modified QI score had a mean of 16.7/28 points (range: 15-21). Thirteen studies investigated kinematics and nine investigated muscle activity. Rowers without LBP ('healthy') have distinct kinematics (neutral or anterior pelvic rotation at the catch, greater hip range of motion, flatter low back spinal position at the finish) and muscle activity (trunk extensor dominant with less flexor activity). Rowers with LBP had relatively greater posterior pelvic rotation at the catch, greater hip extension at the finish and less efficient trunk muscle activity. In both groups fatigue results in increased lumbar spine flexion at the catch, which is greater on the ergometer. There is insufficient evidence to recommend one ergometer type (fixed vs dynamic) over the other to avoid LBP. Trunk asymmetries are not associated with LBP in rowers.

CONCLUSION

Improving clinicians' and coaches' understanding of safe and effective rowing biomechanics, particularly of the spine, pelvis and hips may be an important strategy in reducing incidence and burden of LBP.

Voice and Swallowing Outcomes Following Airway Reconstruction in Adults: A Systematic Review

OBJECTIVES

Laryngotracheal stenosis is a rare condition characterized by upper airway narrowing. Reconstructive surgical treatment aims to manage the area of stenosis to improve dyspnea and can impact voice and swallowing function. This article critically evaluates the literature about voice and swallowing outcomes in adults with laryngotracheal stenosis who undergo reconstructive surgery.

STUDY DESIGN

Systematic review.

METHODS

Six databases were searched for articles referring to voice and swallowing outcome measures following reconstruction procedures in adults with laryngotracheal stenosis. Screening was completed using predefined inclusion/exclusion criteria.

RESULTS

A total of 143 abstracts were reviewed, with 67 articles selected for full-text review. Twenty studies met the inclusion criteria. Data extraction was completed with the Strengthening Reporting of Observational Studies in Epidemiology checklist with Oxford Centre for Evidence-Based Medicine Level of Evidence used to indicate quality. Risk of bias was assessed using the Risk of Bias Assessment Tool for Non-Randomized Studies. All studies scored a high risk of bias in at least one of the domains. Selection and timing of outcome measures was heterogenous, and there was limited information provided about rationale or reliability.

CONCLUSIONS

The literature acknowledges the importance of voice and swallowing outcomes following airway reconstruction. Studies show correlation between reconstructive surgery and deterioration in vocal function; there are no consistent data about swallowing outcomes. The lack of a core outcome measures set for adults with laryngotracheal stenosis limits the findings of this review. Further research is needed to establish clear criteria for robust and clinically relevant outcome measurement. Laryngoscope, 131:146-157, 2021.

The Correlation between Phalangeal Quantitative Ultrasonography and Dual Energy X-ray Absorptiometry in Women with Premature Ovarian Failure

Objectives –With the growing demand for bone densitometry services there is a need for simple, cost-effective and ideally mobile devices which can identify individuals who are at risk of osteoporotic fracture. When new devices are evaluated, it is useful to examine the correlation with the established ‘gold standard’ technique of dual x-ray absorptiometry (DXA). This study examined the correlation between quantitative ultrasound (QUS) measurements performed at the phalanges and conventional DXA measurements of the spine and hip in women with premature ovarian failure – a known risk factor for osteoporosis. Methods - Thirteen white Caucasian women suffering from premature ovarian failure and 19 age- and sex-matched controls were recruited into the study. DXA measurements were performed at the spine and hip, followed by quantitative ultrasonography at phalanges II-V of the non-dominant hand. Results – Significant correlations were observed between the bone transit time (BTT) value from the Bone Profiler and bone mineral density measured at the spine (r=0.66). The spine Z-scores also correlated with many of the ultrasound values (r=0.44 - 0.63). Significant inverse correlations were observed between BMI, weight and ultrasound parameters (r = -0.48 to -0.78). Conclusion – We have reported moderate but significant correlations between phalangeal QUS and DXA parameters. The strongest correlation was observed between BTT and spine BMD, as well as between the Z-scores from the two devices. QUS parameters also demonstrated an inverse correlation with weight and BMI.

The potential for haptic touch technology to supplement human empathetic touch during radiotherapy

Radiotherapy for cancer is an effective treatment but requires precise delivery. Patients are required to remain still in the same position during procedure which may be uncomfortable. This combined with high anxiety experienced by patients, and feelings of isolation, have indicated a need for comfort interventions. Care conveyed through empathetic touch promotes comfort, individual attention and presence and provides both psychological and physical comfort at the same time. Evidence in nursing and care literature showed that empathetic touch interventions have a significant role in promoting comfort, facilitating communication between care recipients and caregivers. However, the application of empathetic touch interventions may be challenging to administer due to the safety concern in the radiotherapy environment. The emergence of haptic technologies that enable the communication of touch remotely may have a potential to fill this gap. We take inspiration from both clinical empathetic touch in radiotherapy practice, as well as affective haptic technologies to envision the opportunities for haptic technologies as a complimentary comfort intervention to supplement human empathetic touch during radiotherapy.

What is the clinical value of mHealth for patients?

Despite growing interest from both patients and healthcare providers, there is little clinical guidance on how mobile apps should be utilized to add value to patient care. We categorize apps according to their functionality (e.g. preventative behavior change, digital self-management of a specific condition, diagnostic) and discuss evidence for effectiveness from published systematic reviews and meta-analyses and the relevance to patient care. We discuss the limitations of the current literature describing clinical outcomes from mHealth apps, what FDA clearance means now (510(k)/de novo FDA clearance) and in the future. We discuss data security and privacy as a major concern for patients when using mHealth apps. Patients are often not involved in the development of mobile health guidelines, and professionals' views regarding high-quality health apps may not reflect patients' views. We discuss efforts to develop guidelines for the development of safe and effective mHealth apps in the US and elsewhere and the role of independent app reviews sites in identifying mHealth apps for patient care. There are only a small number of clinical scenarios where published evidence suggests that mHealth apps may improve patient outcomes.

How do physiotherapists solicit and explore patients' concerns in back pain consultations: a conversation analytic approach

Background: Guidelines advocate that non-specific chronic low back pain (NSCLBP) be considered within a multi-dimensional bio-psychosocial (BPS) framework. This BPS approach advocates incorporating the patient's perspective as part of the treatment process. 'Agenda setting' has been introduced as the key to understanding patients' concerns in medical encounters; however, this has received little attention in physiotherapy. This study explored how physiotherapists solicit and respond to the agenda of concerns that patients with NSCLBP bring to initial encounters. Method: The research setting was primary care. Twenty initial physiotherapy consultations were video-recorded, transcribed and analyzed using conversation analysis, a qualitative observational method. Both verbal and non-verbal features of the interaction were considered. Results: This data highlights a spectrum of communication styles ranging from more physiotherapist-focused, where the physiotherapists did not attend to patients' concerns, to a more patient-focused style, which provided greater opportunities for patients to voice their concerns. On occasions, patients were willing to pursue their own agenda when their concern was initially overlooked. Conclusion: This study provides empirical evidence on communication patterns in physiotherapy practice. A more collaborative style of communication with a shared conversational agenda provided patients with the conversational space to describe their concerns more fully.

The perspectives of physiotherapists on managing nonspecific low back pain following a training programme in cognitive functional therapy: A qualitative study

BACKGROUND

It has long been acknowledged that nonspecific chronic low back pain (NSCLBP) is associated with a complex combination of biopsychosocial (BPS) factors, and recent guidelines advocate that the management of back pain should reflect this multidimensional complexity. Cognitive functional therapy (CFT) is a behaviourally oriented intervention that targets patients' individual BPS profiles. Although the efficacy of CFT has been demonstrated in primary care, little evidence exists about the training requirements of this approach.

METHODS

Qualitative semistructured interviews were conducted with 10 physiotherapists working in primary care, who had undergone a formal training programme in CFT. A purposive sampling method was employed to seek the broadest perspectives. Thematic analysis was used to analyse the interview transcripts and capture the emergent themes.

RESULTS

Five main themes emerged: (i) the learning challenge; (ii) self-reported changes in confidence; (iii) self-reported changes in communication practice; (iv) self-reported changes in attitudes and understanding; (v) the physiotherapists felt that CFT was more effective than their usual approach for NSCLBP but identified barriers to successful implementation, which included a lack of time and difficulties in engaging patients with strong biomedical beliefs.

CONCLUSIONS

The study suggested that training in CFT has the capacity to produce self-reported changes in physiotherapists' attitudes, confidence and practice. The provision of such training has implications in terms of time and costs; however, this this may be warranted, given the physiotherapists' strong allegiance to the approach compared with their usual practice.

Revisiting places passed: Sensitization of exploratory activity in rats with hippocampal lesions

We examined the involvement of the hippocampus in short-term changes in exploratory behaviour in an open field (Experiment 1) and experimental contexts (Experiment 2). In Experiment 1, rats with excitotoxic lesions of the hippocampus were more likely to revisit recently visited zones within the open field than were control rats. Similarly, in Experiment 2 rats with hippocampal lesions showed greater exploration of a context that they had recently explored than a context that they had less recently explored. This short-term sensitization effect was not evident in control rats. These findings are consistent with the suggestion that the recent presentation of a stimulus has two opposing effects on behaviour, sensitization, and habituation, and that hippocampal lesions disrupt the short-term process responsible for habituation, but not that responsible for sensitization.

Delivering an Optimised Behavioural Intervention (OBI) to people with low back pain with high psychological risk; results and lessons learnt from a feasibility randomised controlled trial of Contextual Cognitive Behavioural Therapy (CCBT) vs. Physiotherapy

Background

Low Back Pain (LBP) remains a common and costly problem. Psychological obstacles to recovery have been identified, but psychological and behavioural interventions have produced only moderate improvements. Reviews of trials have suggested that the interventions lack clear theoretical basis, are often compromised by low dose, lack of fidelity, and delivery by non-experts. In addition, interventions do not directly target known risk mechanisms. We identified a theory driven intervention (Contexual Cognitive Behavioural Therapy, CCBT) that directly targets an evidence-based risk mechanism (avoidance and ensured dose and delivery were optimised. This feasibility study was designed to test the credibility and acceptability of optimised CCBT against physiotherapy for avoidant LBP patients, and to test recruitment, delivery of the intervention and response rates prior to moving to a full definitive trial.

Methods

A randomised controlled feasibility trial with patients randomised to receive CCBT or physiotherapy. CCBT was delivered by trained supervised psychologists on a one to one basis and comprised up to 8 one-hour sessions. Physiotherapy comprised back to fitness group exercises with at least 60 % of content exercise-based. Patients were eligible to take part if they had back pain for more than 3 months, and scored above a threshold indicating fear avoidance, catastrophic beliefs and distress.

Results

89 patients were recruited. Uptake rates were above those predicted. Scores for credibility and acceptability of the interventions met the set criteria. Response rates at three and six months fell short of the 75 % target. Problems associated with poor response rates were identified and successfully resolved, rates increased to 77 % at 3 months, and 68 % at 6 months. Independent ratings of treatment sessions indicated that CCBT was delivered to fidelity. Numbers were too small for formal analysis. Although average scores for acceptance were higher in the CCBT group than in the group attending physiotherapy (increase of 7.9 versus 5.1) and change in disability and pain from baseline to 6 months were greater in the CCBT group than in the physiotherapy group, these findings should be interpreted with caution.

Conclusions

CCBT is a credible and acceptable intervention for LBP patients who exhibit psychological obstacles to recovery.

Trial registration

ISRCTN43733490, registered 15/12/2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0594-2) contains supplementary material, which is available to authorized users.

Evaluating rehabilitation following lumbar fusion surgery (REFS): study protocol for a randomised controlled trial

Background

The rate of lumbar fusion surgery (LFS) is increasing. Clinical recovery often lags technical outcome. Approximately 40 % of patients undergoing LFS rate themselves as symptomatically unchanged or worse following surgery. There is little research describing rehabilitation following LFS with no clear consensus as to what constitutes the optimum strategy. It is important to develop appropriate rehabilitation strategies to help patients manage pain and recover lost function following LFS.

Methods/design

The study design is a randomised controlled feasibility trial exploring the feasibility of providing a complex multi-method rehabilitation intervention 3 months following LFS. The rehabilitation protocol that we have developed involves small participant groups of therapist led structured education utilising principles of cognitive behavioral therapy (CBT), progressive, individualised exercise and peer support. Participants will be randomly allocated to either usual care (UC) or the rehabilitation group (RG). We will recruit 50 subjects, planning to undergo LFS, over 30 months. Following LFS all participants will experience normal care for the first 3 months. Subsequent to a satisfactory 3 month surgical review they will commence their allocated post-operative treatment (RG or UC). Data collection will occur at baseline (pre-operatively), 3, 6 and 12 months post-operatively. Primary outcomes will include an assessment of feasibility factors (including recruitment and compliance). Secondary outcomes will evaluate the acceptability and characteristics of a limited cluster of quantitative measures including the Oswestry Disability Index (ODI) and an aggregated assessment of physical function (walking 50 yards, ascend/descend a flight of stairs). A nested qualitative study will evaluate participants’ experiences.

Discussion

This study will evaluate the feasibility of providing complex, structured rehabilitation in small groups 3 months following technically successful LFS. We will identify strengths and weakness of the proposed protocol and the usefulness and characteristics of the planned outcome measures. This will help shape the development of rehabilitation strategies and inform future work aimed at evaluating clinical efficacy.

Trial registration

ISRCTN60891364, 10/07/2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0751-9) contains supplementary material, which is available to authorized users.

Ergometer training volume and previous injury predict back pain in rowing; strategies for injury prevention and rehabilitation

The most commonly reported injury site in rowers is the lower back. Research in recent years has focused on epidemiology and biomechanical analyses to try and understand mechanisms that contribute to this injury's onset. Injury surveillance mainly comprises retrospective questionnaires and reviews of medical records with a lack of prospective data. Of studies that reported 12-month data, the incidence of low back pain ranged from 31.8 to 51% of the cohort. Of the limited studies that specifically examined low back pain in rowers, (1) history of lumbar spine injury and (2) volume of ergometer training were the most significant risk factors for injury onset. Studies of technique on the rowing ergometer have indicated the importance of lumbopelvic rotation during rowing. Greater pelvic rotation at either end of the stroke is ideal-as opposed to lumbar flexion and extension; this tends to be poorly demonstrated in novice rowers on ergometers. Furthermore, technique can deteriorate with the demands of rowing intensity and duration, which puts the rower returning from injury at additional risk.

Is our healthcare system working for spinal surgery patients? Towards individualised care pathways and person-centered supports

As part of a randomised controlled study into the post-operative management of spinal surgery, this qualitative sub-study sought to explore the patients’ experience of the healthcare system and their perceptions of how the system had worked for them, with a view to establishing more appropriate care pathways and improved support materials for patients undergoing surgery.Patients taking part in the FASTER study (Function after spinal treatment, exercise and rehabilitation) were invited during their one year post-operative review to provide feedback on their healthcare experience following surgery. This study comprised 245 patients recruited from 7 hospitals, with 20 different spinal surgeons contributing patients.The majority (82%) of patients were referred through their general practitioner (GP). Forty percent identified a specific event that led to their pain; of these 48% reported a longstanding pain and 33% noted a sudden injury. Thirty percent waited less than a month for surgery and 32% 1-3 months. Eighteen percent experienced surgical cancellations. Many respondents felt that they had not been managed well by their GP pre-operatively, although it appeared that most GPs had followed current guidelines. In terms of their hospital stay the majority felt prepared and content with the care received and expressed faith in their surgical team. Although it appeared that patients were happy with their post-operative care, closer inspection revealed concerns with inadequate information, feelings of abandonment and poor communication from some healthcare professionals. Many reported that taking part in the research itself was a positive experience.Both negative and positive patient experiences have been identified. Patients express concern at the paucity of information they are given concerning their clinical journey, particularly in relation to discharge from hospital. In this era of social media and the internet there is a clear need to explore new methods of addressing patients’ information needs.

Comparison of median frequency between traditional and functional sensor placements during activity monitoring

Long-term monitoring is of great clinical relevance. Accelerometers are often used to provide information about activities of daily living. The median frequency (f_m) of acceleration has recently been suggested as a powerful parameter for activity recognition. However, compliance issues arise when people need to integrate activity recognition sensors into their daily lives. More functional placements should provide higher levels of conformity, but may also affect the quality and generalizability of the signals. How f_m changes as a result of a more functional sensor placement remains unclear. This study investigates the agreement in f_m for a sensor placed on the back with one in the pocket across a range of daily activities. The translational and gravitational accelerations are also computed to determine if the accelerometer should be fused with additional sensors to improve agreement. Twelve subjects were tested over four tasks and only the "vertical" x-axis showed a moderate agreement (Intraclass Correlation Coefficient of 0.54) after correction for outliers. Generalizability across traditional and functional sensor locations might therefore be limited. Differentiation of the signal into a translational and gravitational component decreased the level of agreement further, suggesting that combined information streams are more robust to changing locations then singular data streams. Integrating multiple sensor modalities to obtain specific components is unlikely to improve agreement across sensor locations. More research is needed to explore measurement signals of more user friendly sensor configurations that will lead to a greater clinical acceptance of body worn sensor systems.

Testing the credibility, feasibility and acceptability of an optimised behavioural intervention (OBI) for avoidant chronic low back pain patients: protocol for a randomised feasibility study

BACKGROUND

Chronic back pain continues to be a costly and prevalent condition. The latest NICE guidelines issued in 2009 state that for patients with persistent back pain (of between six weeks and twelve months duration), who are highly distressed and/or disabled and for whom exercise, manual therapy and acupuncture has not been beneficial, the evidence supports a combination of around 100 hours of combined physical and psychological treatment. This is costly, and may prove unacceptable to many patients. A key recommendation of these guidelines was for further randomised controlled trials (RCTs) of psychological treatment and to target treatment to specific sub-groups of patients. Recent trials that have included psychological interventions have shown only moderate improvement at best, and results are not maintained long term. There is therefore a need to test theoretically driven interventions that focus on specific high-risk sub-groups, in which the intervention is delivered at full integrity against a credible control.

METHODS/DESIGN

A feasibility study of a pragmatic randomised controlled trial comparing psychologist-delivered Contextual Cognitive Behavioural Therapy (CCBT) against Treatment As Usual (TAU) physiotherapy delivered by physiotherapists for the treatment of chronic lower back pain in 'avoidant' patients. Ninety-two patients referred for physiotherapy will be recruited and randomised on a 1:1 basis to receive CCBT or TAU. Treatment groups will be balanced by centre and pain interference score. Primary outcomes include assessing the credibility and acceptability of the intervention, and to demonstrate proof of principle through a greater change in pain acceptance in the CCBT arm, measured by the Acceptance and Action -II and the Chronic Pain Acceptance questionnaires. In addition, the feasibility of carrying out a full trial will be explored with reference to recruitment and follow-up rates including the assessment of the burden of outcome measure completion. Secondary patient outcomes include disability, pain, fear of movement, mood, quality of life, and global recovery. Outcomes are measured at three and six months post-randomisation.

DISCUSSION

This paper details the rationale, design, therapist training system and recruitment methods to be used in a feasibility study which will inform the design and efficient implementation of a future definitive RCT.

TRIAL REGISTRATION

ISRCTN43733490.

Exploring the care experience of patients undergoing spinal surgery: a qualitative study

PURPOSE

This exploratory study sought to explore the patient experience of the surgical journey from decision to operate, to hospitalization, discharge and subsequent recovery.

DESIGN

Patients attended one of two focus group discussions.

PATIENT SAMPLE

Seven patients that had undergone surgery for spinal stenosis or disc prolapsed participated, aged between 48-75 years (mean age 59); five were male.

METHODS

Patients' attitudes towards the information and care they received from the point of the decision to operate through to post-operative recovery were explored. Particular attention was paid to patients' information needs, support provided, general understanding of the processes and ways in which care could have been improved.

RESULTS

Patients identified nine main 'needs' they felt played an integral part in enhancing the patient experience including the need for reduced waiting times, for better information and preparation, to be proactive, to speak up and ask questions, to feel safe and to be treated with dignity and respect; and the need for ongoing support, human contact, and; continuity of care.

CONCLUSION

These findings suggest that there are several measures that could be taken to improve the patient's surgical experience. In particular, providing appropriate information to patients in a timely manner and ensuring that support and advice is easily accessible for those patients that need it are key areas for improvement.

Joint spatio-temporal registration and microvasculature segmentation of retinal angiogram sequences

We discuss the problem of 2D+t intra- and inter-sequential registration of retinal angiograms. A joint spatio-temporal registration algorithm is presented based on a RANSAC (RANdom SAmple Consensus) approach incorporating a quadratic model to describe "pairwise" image homography. This is incorporated into a local-to-global hierarchical joint registration framework. After registration, vessel centrelines are segmented to subpixel accuracy by applying multi-scale steerable complex wavelet filters. Frame-by-frame microvascular centrelines in Regions-of-Interest (ROIs) are evaluated against segmented centrelines of the temporal average of the registered sequences. The microvascular centrelines in registered sequences can be compared intra-sequentially and inter-sequentially, allowing non-invasive clinical monitoring of micro-circulation. This has the potential to detect the presence of microemboli and pathological structural alterations.

Guinea pig cytomegalovirus GP84 is a functional homolog of the human cytomegalovirus (HCMV) UL84 gene that can complement for the loss of UL84 in a chimeric HCMV

The guinea pig cytomegalovirus (GPCMV) co-linear gene and potential functional homolog of HCMV UL84 (GP84) was investigated. The GP84 gene had delayed early transcription kinetics and transient expression studies of GP84 protein (pGP84) demonstrated that it targeted the nucleus and co-localized with the viral DNA polymerase accessory protein as described for HCMV pUL84. Additionally, pGP84 exhibited a transdominant inhibitory effect on viral growth as described for HCMV. The inhibitory domain could be localized to a minimal peptide sequence of 99 aa. Knockout of GP84 generated virus with greatly impaired growth kinetics. Lastly, the GP84 ORF was capable of complementing for the loss of the UL84 coding sequence in a chimeric HCMV. Based on this research and previous studies we conclude that GPCMV is similar to HCMV by encoding single copy co-linear functional homologs of HCMV UL82 (pp71), UL83 (pp65) and UL84 genes.