Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial

BACKGROUND

Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another.

METHODS

This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59).

RESULTS

The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points.

CONCLUSIONS

The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.

Immunoreactive myelin basic protein in the cerebrospinal fluid in neurological disorders

Cerebrospinal fluid from 582 persons was analyzed by a double-antibody radioimmunoassay for the presence of material cross-reactive with peptide 43-88 of human myelin basic protein (BP). In a group of 104 patients with multiple sclerosis (MS), 23 of 33 individuals clinically judged to have had an exacereation within two weeks prior to the time CSF was obtained had detectable material ranging from 2 to 200 ng/ml. In the remaining 71 MS patients who either were stable or had had an exacerbation more than two weeks before, only 1 patient had a marginally elevated level of immunoreactive material. CSF from 53 persons with cerebrovascular disease was studied, and 13 of 29 with recent infarctions had values of 2 to 540 ng/ml. The degree of elevation in strokes generally paralleled the predicted volume of the lesion, but the amounts detected did not correlate quite so closely temporally with onset as they did with the periods of active disease in MS. Of the remaining 425 patients, 29 had immunoreactive material of 2 to 400 ng/ml in their CSF. Most of these patients with detectable material had acute diseases known to affect the myelin sheath. Eight of 10 persons with acute disseminated encephalomyelitis had no detectable material. The presence in CSF of material cross-reactive with BP peptide 43-88 does not have diagnostic specificity for MS but can be used as a means for determining recent myelin injury. The type of BP peptide formed and mechanisms for clearance of BP and BP peptides may be important in determining the biological consequences following release of this potentially immunogenic material from the central nervous system.

Health care utilization and functional status in the aged following a fall

Falls in the aged may lead to increases in health care utilization and declines in functional status. The Longitudinal Study of Aging was analyzed to test the hypotheses that use of the health care system is greater in elderly persons subsequent to a fall in the preceding year than in those who have not fallen and that fallers are more likely to decline in function than are nonfallers. One-time fallers and, especially repeated fallers, (2 or more falls in the preceding year) were at greater risk of subsequent hospitalization, nursing home admission, and frequent physician contact than were nonfallers, after controlling for age, sex, self-perceived health status, and difficulties with activities of daily living. Similarly, one-time fallers, and especially repeated fallers, were at greater risk of reporting subsequent difficulties with activities of daily living, instrumental activities of daily living, and more physically demanding activities. These findings highlight the significant impact that falls have on the health care system and on the individual.

Use of the ED as a regular source of care: associated factors beyond lack of health insurance

STUDY OBJECTIVE

To determine the characteristics and health care experiences of patients who identify the ED as their usual source of care.

METHODS

We conducted a cross-sectional survey in a Level I trauma center ED at an urban teaching hospital. Our population comprised 892 adults who presented to the ED over the course of 30 days. We asked participants about their regular source of health care, previous health care experiences, and perceptions of the use of the ED.

RESULTS

Patients who reported the ED as their regular source of care were three times more likely to have used the ED more than once in the preceding year. Among the regular ED users, 68% desired a physician as their regular source of care, and 46% of these subjects said they had tried unsuccessfully to get one in the preceding year. Five variables were associated with self-report of the ED as the regular source of health care: annual income less than $30,000, having been refused care in an office or clinic in the past, perception that an ED visit costs less than an office visit, absence of chronic illness, and unwillingness to use the ED if a $25 copayment were in effect.

CONCLUSION

Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care. These factors suggest the difficulty of altering health care use patterns in this group.

Who leaves against medical advice?

Patients who leave hospitals against medical advice (AMA) frustrate physicians and may put themselves at medical risk. A case-control study was conducted to characterize the factors associated with AMA discharges from an impatient medical service. Logistic regression analysis indicated that not having a primary care physician and previous AMA discharge were significantly associated with leaving AMA. The patients most often stated that they were leaving because they "felt better" or had personal or financial obligations. However, the patients leaving AMA were more likely to return for care within the next week than were the control patients.

Correlates of disruptive behavior in severely cognitively impaired nursing home residents

This article provides information about correlates of "disruptive behaviors" among nursing home residents with dementia. We used averages of multiple observations for a wide range of behaviors (n = 45) across 11 months to gather this information. We placed behaviors into four separate categories: physically aggressive, physically non-aggressive, vocally agitated, and vocally aggressive. Then, we tested associations between these categories and demographic, cognitive, and health variables. Cognitive status and selected demographic variables were associated with the behavior categories; adding health variables did not improve prediction. Lower cognitive status was associated with more disruptive behaviors. Our findings suggest that cognitive status, but not health variables, predicts disruptive behavior among nursing home residents with dementia.

Malignant chest wall neoplasms of bone and cartilage: a pictorial review of CT and MR findings

Malignant tumours of the chest wall are uncommon. The purpose of this pictorial essay is to describe the CT and MRI findings of malignant neoplasms affecting the bony skeleton of the chest wall and the costal cartilages. The most common primary malignant neoplasms involving the bony skeleton of the chest wall are chondrosarcoma, osteosarcoma and Ewing's sarcoma/primitive neuroectodermal tumour. Metastases, multiple myeloma and invasive primary lung cancer are the most frequent secondary lesions. We performed a retrospective review of the radiology and pathology archive at our institution from 1 July 2000 to 31 December 2004 and identified 31 of these lesions. Several of these tumours have distinctive radiological features, allowing a confident radiological diagnosis to be suggested.

An intrathecal fentanyl dose-response study in lower extremity revascularization procedures

BACKGROUND

Intrathecal opioids routinely are administered to surgical patients to provide prolonged postoperative analgesia. This study evaluated the dose-response effects of intrathecal fentanyl in an elderly patient population undergoing lower extremity revascularization procedures.

METHODS

Surgical anesthesia was induced using a continuous spinal technique. No patient received perioperative antiemetics or opioids. Postoperatively, after complete regression of spinal anesthesia, patients received via the spinal catheter either 0, 5, 10, 20, 40, or 50 micrograms fentanyl. Blood pressure, heart rate, respiratory rate, oxyhemoglobin saturation, and visual analog pain scores were recorded approximately every minute for 15 min after study drug administration. After this initial observation period, blood pressure, heart rate, respiratory rate, oxyhemoglobin saturation were recorded every 15 min for the next 2 h, then every 30 min thereafter. A verbal analog pain score, with 0 equivalent to no pain and 10 the worst pain imaginable, was obtained with each set of vital signs. The study was concluded when the verbal analog pain score was > or = 3, the patient was medicated, and the time was recorded. Any side effects, such as respiratory depression, nausea, vomiting, and pruritus, were recorded.

RESULTS

Minimal analgesia was derived from the 0-, 5-, and 10-micrograms doses. Beginning at 20 micrograms, patients experienced the onset of satisfactory analgesia (visual analog pain scores < 3) within 4 min. All patients in the 40- and 50-micrograms groups had excellent analgesia (visual analog pain scores < 1) within 10 min. No patient experienced respiratory depression (respiratory rate < 9 breaths/min), hypoxemia (oxyhemoglobin saturation < 90%), or any hemodynamic alterations (20% change greater or less than baseline heart rate or blood pressure). In the 50-micrograms group, five of ten patients complained of pruritus.

CONCLUSIONS

Results indicate that 40 micrograms intrathecal fentanyl provides satisfactory analgesia for approximately 5 h in an elderly patient population, with a low incidence of side effects.

Effects of presentation method on the understanding of informed consent

BACKGROUND/AIM

Knowledge of which presentation methods impart the most information to patients can improve the informed consent discussion. The purpose of this study was to determine if the comprehension and recall of the informed consent discussion varied with presentation method.

METHODS

Randomised, prospective study at the University of Arkansas for Medical Sciences. 90 freshmen medical students were randomly assigned to one of three groups and separately went through an informed consent on cataract surgery. Group A heard an informed consent presentation. Group B was shown diagrams while hearing the same presentation. Group C heard the consent and then watched an informational video on cataract surgery. A 10 point multiple choice quiz was administered after the presentation and repeated again 1 week later.

RESULTS

Scores from each group were averaged as number correct out of 10 questions. For same day scores, group C scores (7.70 (SD 1.24)) were significantly higher than group A (6.39 (1.63)). One week testing revealed that group C (6.96 (1.62)) recalled more between the two time periods and scored significantly higher than groups A (5.15 (2.11)) and B (5.54 (1.64)).

CONCLUSIONS

This study found differences in the participants' ability to recall facts based on the manner in which the material was presented. It clearly demonstrated that the use of visual aids improved the ability to remember facts and risks associated with cataract surgery beyond a verbal presentation alone. It also showed a benefit of the repetition of information as provided by audiovisual presentations that can be used in conjunction with the physician-patient discussion.

Practice guidelines to reduce testing in the hospital

OBJECTIVE

To reduce testing among hospitalized patients using practice guidelines for any of 14 medical problems.

DESIGN

Comparison of test use before and after implementation of guidelines. The guidelines were developed by consensus panels of self-selected participating physicians. Non-participating physicians were monitored during the same periods. In addition, the two groups of physicians were evaluated similarly for their management of three medical problems for which guidelines were not developed.

SETTING

Acute care hospital.

PATIENTS/PARTICIPANTS

1,638 hospitalized patients and their 79 physicians.

INTERVENTION

Implementation of practice guidelines for the care of hospitalized patients.

MEASUREMENT AND MAIN RESULTS

Geometric mean charges expressed in inflation-adjusted dollars were used as measures of test use. For the intervention group, laboratory tests decreased by 20.6%, x-rays by 42.3%, and EKGs by 34.2%. All the decreases were significant (p = 0.001). The non-participating physicians who were higher test users during both years of the study also achieved significant (p less than 0.05) but smaller reductions during the intervention year: 13.9% for laboratory tests, 30.3% for x-rays, and 21.8% for EKGs, perhaps because the same residents were involved in the care of both groups of patients. For the non-guideline diagnoses, the participating physicians achieved reductions of 11.1% for laboratory tests and 19.2% for x-rays, and a 3.5% increase in EKGs. Two-way analyses of variance that took into account the reductions in testing achieved by non-participants, or by participants with non-guideline diagnoses, revealed no significant reduction in testing attributable directly to the guidelines except for EKGs. Follow up of the participating physicians during the six months after the end of the intervention revealed that testing remained at the lower level achieved while the guidelines were in use. Outcome of care, as measured by deaths in the hospital, deaths within 90 days of discharge, and readmissions within 90 days of discharge, was not affected by the use of the guidelines.

CONCLUSIONS

1) A large group of physicians could be recruited in a hospital to establish practice guidelines by group consensus. 2) These self-selected physicians were willing to use the guidelines (or allow the housestaff to use them) while caring for their patients. 3) Participating physicians were able to achieve substantial and significant reductions in testing without any demonstrable adverse effect on quality of care as measured by deaths and readmissions, and without any demonstrable shifting of resources from the inpatient to the outpatient setting of care. 4) The reductions in testing, whether caused by the guidelines or not, persisted for at least six months beyond the end of the period of implementation.

Causes of death in persons with human immunodeficiency virus infection

PURPOSE

Pneumocystis carinii pneumonia (PCP) was reported to be the predominant cause of human immunodeficiency virus (HIV)-related deaths prior to 1988, the year that effective prophylaxis against PCP entered routine use. Our study was performed to study the causes of HIV-related death since January 1988 in a region where patient tracking is virtually complete.

PATIENTS AND METHODS

We surveyed physicians associated with the Brown University Acquired Immunodeficiency Syndrome (AIDS) Program who cared for greater than 95% of known HIV-positive patients in Rhode Island. These physicians identified all those HIV-infected persons who had died under their care between January 1988 and July 1990, and determined these patients' causes of death by chart review. For comparison, death certificates of identified persons were also reviewed at the Rhode Island Department of Vital Statistics.

RESULTS

Among 126 deaths since January 1988, bacterial infections were the most common cause of death (30%), whereas PCP was responsible for only 16% of deaths. Persons not receiving any form of PCP prophylaxis were more likely to die from PCP than were those who received prophylaxis (26% versus 11% [p = 0.04]). Cause of death as recorded on actual death certificates was imprecise, although bacterial infections were again the most common cause indicated. Only one death occurred in a patient with a CD4 count greater than 200/mL, and this was not HIV-related.

CONCLUSION

PCP has not been the leading cause of death in our region since January 1988. Bacterial infections contribute substantially to mortality, and this may influence future prophylactic regimens. HIV-related deaths in patients with CD4 counts greater than 200/mL are unusual.

The metabolic impact of active ulcerative colitis. Energy expenditure and nitrogen balance

Resting energy expenditure and nitrogen balance were measured shortly after admission and shortly before discharge or colectomy in eight adult males hospitalized for active ulcerative colitis. The measured resting energy expenditure was 19% higher than that predicted by the Harris-Benedict formula (p less than 0.01). Fecal and urinary nitrogen losses were 2.1 +/- 1.5 g/day and 13.6 +/- 3.8 g/day, respectively. During the early hospitalization period, daily intakes of calories (1,826 +/- 1,050 kcal) and protein (1.5 +/- 0.4 g/kg) were not sufficient to maintain energy (-548 +/- 964 kcal/day) and nitrogen (-1.5 +/- 3.9 g/day) balances. Energy expenditure and nitrogen losses at the end of the study were similar to the values obtained on admission, but because of a voluntary increase in caloric (by 42%) and protein (by 37%) intake during the hospitalization both energy balance (+434 +/- 409 kcal/day) and nitrogen balance (+4.6 +/- 6.5 g/day) (p less than 0.05) improved. These results suggest that, although the metabolic impact of active ulcerative colitis is mild, it does result in negative energy and nitrogen balances. Dietary intake can be voluntarily increased during hospitalization to improve energy and nitrogen equilibrium.

Does peppermint oil relieve spasm during barium enema?

The effectiveness of topical peppermint oil added to barium sulphate suspension in relieving colonic muscle spasm during double contrast barium enema examination was assessed in a double blind study. 141 patients were randomized either to a control group (71 patients) examined with standard barium suspension or to the treatment group which received peppermint oil mixed with the barium preparation. No residual spasm was evident in a significant proportion of patients in the treated group (60%) compared with the control group (35%) (p < 0.001). The patients' acceptability of the procedure was good and there were no adverse effects on the overall quality of the examination. In conclusion, the addition of peppermint oil to the barium suspension seems to reduce the incidence of colonic spasm during the examination. The technique is simple, safe, cheap and it may lessen the need for intravenous administration of spasmolytic agents.

Eradicating BVD, reviewing Irish programme data and model predictions to support prospective decision making

Bovine Viral Diarrhoea is an infectious production disease of major importance in many cattle sectors of the world. The infection is predominantly transmitted by animal contact. Postnatal infections are transient, leading to immunologically protected cattle. However, for a certain window of pregnancy, in utero infection of the foetus results in persistently infected (PI) calves being the major risk of BVD spread, but also an efficient target for controlling the infection. There are two acknowledged strategies to identify PI animals for removal: tissue tag testing (direct; also known as the Swiss model) and serological screening (indirect by interpreting the serological status of the herd; the Scandinavian model). Both strategies are effective in reducing PI prevalence and herd incidence. During the first four years of the Irish national BVD eradication programme (2013-16), it has been mandatory for all newborn calves to be tested using tissue tag testing. During this period, PI incidence has substantially declined. In recent times, there has been interest among stakeholders in a change to an indirect testing strategy, with potential benefit to the overall programme, particularly with respect to cost to farmers. Advice was sought on the usefulness of implementing the necessary changes. Here we review available data from the national eradication programme and strategy performance predictions from an expert system model to quantify expected benefits of the strategy change from strategic, budgetary and implementation points of view. Key findings from our work include (i) drawbacks associated with changes to programme implementation, in particular the loss of epidemiological information to allow real-time monitoring of eradication progress or to reliably predict time to eradication, (ii) the fact that only 25% of the herds in the Irish cattle sector (14% beef, 78% dairy herds) would benefit financially from a change to serosurveillance, with half of these participants benefiting by less than EUR 75 per annum at herd level or an average of EUR 1.22 per cow, and (iii) opportunities to enhance the effectiveness of the current programme, particularly in terms of time to eradication, through enforced compliance with PI removal as currently outlined in programme recommendations. The assembled information provides scientific arguments, contributing to an informed debate of the pros and cons of a change in eradication strategy in Ireland.

Racial differences in breast cancer screening among women from 65 to 74 years of age: trends from 1987-1993 and barriers to screening

Breast cancer mortality is decreasing for elderly white women but increasing for elderly black women. National surveys were used to study racial differences in breast cancer screening and effects of Medicare funding for mammography and to examine explanatory fac- tors. A total of 13,545 women, aged 65-74, from the Health Care Finance Administration's Master Beneficiary File participated. After Medicare funding for screening mammography, the percent reporting a mammogram increased for white women, but not for black women. Clinical breast examination and breast self-examination decreased. Physician's recommendation, geographic area, education level and health status were the variables significantly affecting mammography usage for both races. Physicians recommended mammography more often if women were white, married, educated beyond high school and had an annual income greater than $20,000. These results support the need to design and test strategies specifically for black women and interventions to emphasize physician recommendations for breast cancer screening.

Soft tissue tumours and mass-like lesions of the chest wall: a pictorial review of CT and MR findings

Soft tissue tumours and tumour-like lesions of the chest wall are uncommon. The purpose of this pictorial essay is to describe the imaging findings of chest wall soft tissue tumours and tumour-like lesions. We searched the radiological and pathological archive at our institution retrospectively and reviewed the literature on soft tissue tumours of the chest wall. Common chest wall soft tissue tumours and mass-like lesions include peripheral nerve tumours, lipomas, liposarcomas, haemangiomas, elastofibromas, metastases, lymphoma and abscesses. Other lesions encountered include desmoid tumours and malignant fibrous histiocytoma. Many have distinctive radiological findings or occur in specific locations, allowing a specific radiological diagnosis to be suggested.

Extragonadal endodermal sinus tumors in children: a review of 24 cases

Endodermal sinus tumors (EST) are highly malignant lesions with a tendency to recur locally and with a high incidence of metastatic disease at the time of diagnosis. The clinical and radiographic spectra of 24 patients with extragonadal EST are reported. There were 17 females and seven males and the mean age of presentation was 21 months. The primary lesion occurred in the sacrococcygeal region in 16 patients; in the vagina in two patients; in the anterior mediastinum in two patients; and in the bladder, liver, nasopharynx and posterior cranial fossa in one patient each. Computed tomography (CT) is the most accurate study in delineating the extent of primary lesions particularly in the pelvis and head and neck and also for demonstrating metastatic disease in the lungs. Significant improvement in survival rates is obtained with a combination of surgery, chemotherapy and radiotherapy.

Benign versus malignant breast disease: comparison of contrast-enhanced MR imaging and Tc-99m tetrofosmin scintimammography

PURPOSE

To compare technetium-99m tetrofosmin scintimammography with contrast material-enhanced magnetic resonance (MR) imaging in the characterization of palpable breast masses.

MATERIALS AND METHODS

Forty-seven patients (mean age, 51 years) with a palpable breast mass were prospectively examined with scintimammography, MR imaging, and conventional mammography 2 weeks before fine-needle aspiration biopsy.

RESULTS

In three patients, MR imaging was aborted. Of the remaining 44 patients, 21 had biopsy-proved cancer and 23 had benign disease. The sensitivity of mammography was 81%; specificity, 82%; positive predictive value (PPV), 85%; and negative predictive value (NPV), 78%. The sensitivity of scintimammography was 95%; specificity, 91%; PPV, 91%; and NPV, 95%. The sensitivity of MR imaging was 90%; specificity, 91%; PPV, 90%; and NPV, 91%. In 11 patients with previous breast cancer, scintimammographic findings were positive in all four with tumor recurrence and negative in all seven with benign disease. Masses were correctly characterized with MR imaging in eight of these 11 patients.

CONCLUSION

Although both techniques accurately differentiate benign from malignant palpable breast masses, scintimammography is more accurate in the posttreatment breast. Because of lower cost, wider availability, and high patient acceptance, scintimammography may provide a valuable alternative to MR imaging for noninvasive characterization of palpable breast disease.

Evaluating Critical Thinking Skills of Baccalaureate Nursing Students

This study evaluates the critical thinking skills of students enrolled in a baccalaureate nursing program, using the WGCTA, for the classes of 1993 through 1996. Scores were obtained at entry and at end of junior and senior years. The mean entry WGCTA score was 56 for all four classes; however, the 1995 and 1996 classes had significantly higher scores than the class of 1994. Critical thinking scores were higher at entry for older students and students who had completed another education degree; however, critical thinking scores were lower for students who had previous nursing experience. After adapting for age, previous degree, and nursing experience, no significant differences in the WGCTA scores from entry to end of junior and senior years emerged for the classes of 1993, 1994, 1995. Critical thinking skills have become the hallmark of education. The National Education Goal Panel has advocated for an increase in the ability to think critically, communicate effectively and solve problems (Banta, 1993). In turn, the nursing profession has incorporated these goals of higher education into its educational programs. The National League for Nursing (NLN) includes the measurement of critical thinking as a required outcome in the evaluation and accreditation of baccalaureate and higher degree programs in nursing. This critical thinking outcome must reflect the student's skill in analysis, reasoning, research, or decision making as these skills relate to the nursing discipline (National League for Nursing, 1992). To meet the NLN's critical thinking outcome criterion, nursing programs must have a method of evaluating this skill. Many programs use the Watson-Glaser Critical Thinking Appraisal (WGCTA), which is a standardized instrument. The College of Nursing at the University of Arkansas for Medical Sciences (UAMS) adopted this instrument to evaluate the critical thinking skills of students in the baccalaureate nursing program.

Treatment of “High-Flow” Priapism with Superselective Transcatheter Embolization: A Useful Alternative to Surgery

PURPOSE

To review the efficacy of treatment of high-flow priapism with superselective transcatheter embolization.

METHODS

Over a 2-year period, we reviewed five patients who were treated for traumatic high-flow priapism with superselective embolization. All patients underwent diagnostic angiography that demonstrated a communication between the cavernosal artery and the corpora cavernosa. Each identified fistula was embolized using gel-foam, blood clot, microcoils, or a combination of these.

RESULTS

All five patients had successful detumesence of priapism postprocedure. There was normal recurrence of early morning erection with successful detumescence for each patient within a 2- to 4-week period. Two of five patients (40%) presented with recurrence of priapism at 6 months and required a repeat embolization procedure. At 1 year, four of the five patients (80%) had normal erectile function.

CONCLUSION

Superselective transcatheter embolization is a useful therapeutic modality in the treatment of high-flow priapism. It provides equivalent rates of detumesence when compared to surgical techniques, and appears to have a greater success in preserving erectile function.

The Use of Progressive Indicators as Predictors of NCLEX-RN Success and Performance of BSN Graduates

Successful performance during the student's academic career contributes to his success on the NCLEX-RN. The purpose of this study was to determine predictors of success on the NCLEX preadmission and years 2, 3, and 4 variables in relation to NCLEX-RN scores. Data were obtained retrospectively from records of 408 baccalaureate nursing students. Preadmission variables were sex, age, race, and admission grade point average (GPA). Year 2 variables were numerical grades for the first two clinical nursing courses. Year 3 variables were numerical grades for clinical courses in mental health, adult health, and maternal child nursing. Year 4 variables were numerical grades in two senior clinical courses, percentile rank on NLN comprehensive exam, and graduate GPA. In NCLEX-RN scores, 67% of the variance was accounted for by admission GPA and race (33%), one 2nd year grade (an additional 14%), the 3rd year adult health grade (an additional 14%), the 3rd year adult health grade (an additional 11%), one 4th year theory grade, and the NLN comprehensive exam (an additional 9%). These results suggest that there are preadmission and sophomore year predictors of NCLEX-RN success which could be used to design early interventions for students performing poorly and at risk of failing the NCLEX-RN.

RESTORE-Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain: study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading cause of disability globally and its costs exceed those of cancer and diabetes combined. Recent evidence suggests that individualised cognitive and movement rehabilitation combined with lifestyle advice (cognitive functional therapy (CFT)) may produce larger and more sustained effects than traditional approaches, and movement sensor biofeedback may enhance outcomes. Therefore, this three-arm randomised controlled trial (RCT) aims to compare the clinical effectiveness and economic efficiency of individualised CFT delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling LBP.

METHODS AND ANALYSIS

Pragmatic, three-arm, randomised, parallel group, superiority RCT comparing usual care (n=164) with CFT (n=164) and CFT-plus-movement-sensor-biofeedback (n=164). Inclusion criteria include: adults with a current episode of LBP >3 months; sought primary care ≥6 weeks ago for this episode of LBP; average LBP intensity of ≥4 (0-10 scale); at least moderate pain-related interference with work or daily activities. The CFT-only and CFT-plus-movement-sensor-biofeedback participants will receive seven treatment sessions over 12 weeks plus a 'booster' session at 26 weeks. All participants will be assessed at baseline, 3, 6, 13, 26, 40 and 52 weeks. The primary outcome is pain-related physical activity limitation (Roland Morris Disability Questionnaire). Linear mixed models will be used to assess the effect of treatment on physical activity limitation across all time points, with the primary comparison being a formal test of adjusted mean differences between groups at 13 weeks. For the economic (cost-utility) analysis, the primary outcome of clinical effect will be quality-adjusted life years measured across the 12-month follow-up using the EuroQol EQ-5D-5L .

ETHICS AND DISSEMINATION

Approved by Curtin University Human Research Ethics Committee (HRE2018-0062, 6 Feb 2018). Study findings will be disseminated through publication in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618001396213).