Low-dose naltrexone for post-COVID fatigue syndrome: a study protocol for a double-blind, randomised trial in British Columbia

INTRODUCTION

A significant proportion of individuals suffering from post COVID-19 condition (PCC, also known as long COVID) can present with persistent, disabling fatigue similar to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-viral fatigue syndromes. There remains no clear pharmacological therapy for patients with this subtype of PCC, which can be referred to as post-COVID fatigue syndrome (PCFS). A low dose of the opioid antagonist naltrexone (ie, low-dose naltrexone (LDN)) has emerged as an off-label treatment for treating fatigue and other symptoms in PCC. However, only small, non-controlled studies have assessed LDN in PCC, so randomised trials are urgently required.

METHODS AND ANALYSIS

A prospective, randomised, double-blind, parallel arm, placebo-controlled phase II trial will be performed to assess the efficacy of LDN for improving fatigue in PCFS. The trial will be decentralised and open to eligible individuals throughout the Canadian province of British Columbia (BC). Participants will be recruited through the province-wide Post-COVID-19 Interdisciplinary Clinical Care Network (PC-ICCN) and research volunteer platform (REACH BC). Eligible participants will be 19-69 years old, have had a confirmed or physician-suspected SARS-CoV-2 infection at least 3 months prior and meet clinical criteria for PCFS adapted from the Institute of Medicine ME/CFS criteria. Individuals who are taking opioid medications, have a history of ME/CFS prior to COVID-19 or history of significant liver disease will be excluded. Participants will be randomised to an LDN intervention arm (n=80) or placebo arm (n=80). Participants in each arm will be prescribed identical capsules starting at 1 mg daily and follow a prespecified schedule for up-titration to 4.5 mg daily or the maximum tolerated dose. The trial will be conducted over 16 weeks, with assessments at baseline, 6, 12 and 16 weeks. The primary outcome will be fatigue severity at 16 weeks evaluated by the Fatigue Severity Scale. Secondary outcomes will include pain Visual Analogue Scale score, overall symptom severity as measured by the Patient Phenotyping Questionnaire Short Form, 7-day step count and health-related quality of life measured by the EuroQol 5-Dimension questionnaire.

ETHICS AND DISSEMINATION

The trial has been authorised by Health Canada and approved by The University of British Columbia/Children's and Women's Health Centre of British Columbia Research Ethics Board. On completion, findings will be disseminated to patients, caregivers and clinicians through engagement activities within existing PCC and ME/CFS networks. Results will be published in academic journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT05430152.

Analgesia for the treatment of acute pancreatitis: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Gastrointestinal hospitalisations in the USA cause over US$130 billion in expenditures, and acute pancreatitis is a leading cause of these hospitalisations. Adequate pain control is one of the primary treatment goals for acute pancreatitis. Though opioids are commonly used for analgesia in these patients, there have been concerns about short-term and long-term side effects of using opioids. Recently, non-opioid medications have been studied to treat pain in patients with acute pancreatitis. This systematic review and network meta-analysis aims to assess the comparative efficacy of analgesic medication for non-severe, acute pancreatitis.

METHODS AND ANALYSIS

We will search multiple electronic databases for randomised controlled trials that study pain management in patients with non-severe, acute pancreatitis. The intervention will be any analgesic for acute pancreatitis in the hospital setting. The comparison group will be patients who received a placebo or other active interventions for pain management. The primary outcomes of interest include pain scores and the need for supplementary analgesia. The secondary outcomes will be serious adverse events, local complications, progression to severe pancreatitis, transfer to the intensive care unit, length of hospitalisation, time to start enteral feeds, 30-day all-cause mortality and Quality of Life Scale scores. If sufficient homogeneity exists among included studies, the findings will be pooled using a traditional pairwise and network meta-analysis. The risk of bias in randomised control trials will be evaluated using the Cochrane Risk of Bias Tool 2.0. The Grading of Recommendations, Assessment, Development, and Evaluation approach will be used to report the certainty of evidence.

ETHICS AND DISSEMINATION

This systematic review will not involve direct contact with human subjects. The findings of this review will be published in a peer-reviewed journal. They will give healthcare providers a better awareness of the optimal analgesic medication for pain treatment in non-severe, acute pancreatitis.

Pain Neuroscience Education in elective surgery patients: study protocol for a randomised controlled trial

BACKGROUND

Pain Neuroscience Education (PNE) consists of an educational strategy that seeks to understand the biological processes of pain and how to control it. The main objective of this study will be to evaluate the impact of PNE on outcomes related to the postoperative period. The hypothesis is that the intervention may positively influence postoperative recovery, contributing to pain control, clinical indications, acceptance and consumption of analgesics and other pharmacological drugs that contribute to its control, as well as psychological aspects, such as anxiety, depression and pain catastrophising.

METHODS AND ANALYSIS

This will be an open, parallel, multicentre and randomised controlled clinical trial. A total of 100 participants aged between 18 and 59 years of age, of both genders, who are going to have elective general surgery will be evaluated. The intervention group will participate in a preoperative pain neuroscience educational session and also receive usual preoperative care, while the control group receives usual preoperative care as well. The educational session will last 30 min and consists of a video (5:20 min), a questionnaire about the content, time for participants to express their beliefs, thoughts and doubts. Participants will be evaluated preoperatively and there will be one postintervention evaluation. The intensity and characteristics of pain and anxiety are evaluated as primary outcomes. As secondary outcomes, pain catastrophising and depression are taken into account.

ETHICS AND DISSEMINATION

The project was approved by the Research Ethics Committee of the Faculty of Ceilandia, the Research Ethics Committee of the Institute of Strategic Health Management of the Federal District and the Research Council of the Hospital of Brasília-Rede Dasa (CAAE: 28572420.3.0000.8093). Recruitment began in June of 2023. All participants were included in the study only after their written consent. All data obtained will be analysed and distributed through publication in journals and at scientific events.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ReBEC) (RBR-23mr7yy).

Skeletal muscle relaxants as adjunctive pain control following cardiothoracic surgery: a systematic review protocol

INTRODUCTION

Multimodal pain control following cardiothoracic surgery remains a focus in international guidelines. We hypothesise that non-depolarising skeletal muscle relaxants can prove to be a useful adjunct for this population.

METHODS/ANALYSIS

This systematic review will focus on human adult studies of pain control using muscle relaxants within 1 week following cardiac and thoracic surgery available in PubMed, Cochrane Central, Web of Science and EMBASE. Target studies will have a primary focus on measured effects on quality of pain control and reduction in opioid usage. Studies that include non-depolarising skeletal muscle relaxants given during cardiothoracic surgery or in the week after will be included. Study selection will be in keeping with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Procedures and agents used will be analysed together, and a meta-analysis will be conducted then compared with current therapies recommended in international practice guidelines.

ETHICS AND DISSEMINATION

Formal ethical approval will not be required as primary data will not be collected. The results will be disseminated through peer-reviewed publication, conference presentation and lay press.

PROSPERO REGISTRATION NUMBER

CRD42023397917.

Pancreatic quantitative sensory testing to predict treatment response of endoscopic therapy or surgery for painful chronic pancreatitis with pancreatic duct obstruction: study protocol for an observational clinical trial

INTRODUCTION

Treatment for abdominal pain in patients with chronic pancreatitis (CP) remains challenging in the setting of central nervous system sensitisation, a phenomenon of remodelling and neuronal hyperexcitability resulting from persistent pain stimuli. This is suspected to render affected individuals less likely to respond to conventional therapies. Endotherapy or surgical decompression is offered to patients with pancreatic duct obstruction. However, the response to treatment is unpredictable. Pancreatic quantitative sensory testing (P-QST), an investigative technique of standardised stimulations to test the pain system in CP, has been used for phenotyping patients into three mutually exclusive groups: no central sensitisation, segmental sensitisation (pancreatic viscerotome) and widespread hyperalgesia suggestive of supraspinal central sensitisation. We will test the predictive capability of the pretreatment P-QST phenotype to predict the likelihood of pain improvement following invasive treatment for painful CP.

METHODS AND ANALYSIS

This observational clinical trial will enrol 150 patients from the University of Pittsburgh, Johns Hopkins and Indiana University. Participants will undergo pretreatment phenotyping with P-QST. Treatment will be pancreatic endotherapy or surgery for clearance of painful pancreatic duct obstruction.

PRIMARY OUTCOME

average pain score over the preceding 7 days measured by Numeric Rating Scale at 6 months postintervention. Secondary outcomes will include changes in opioid use during follow-up, and patient-reported outcomes in pain and quality of life at 3, 6 and 12 months after the intervention. Exploratory outcomes will include creation of a model for individualised prediction of response to invasive treatment.

ETHICS AND DISSEMINATION

The trial will evaluate the ability of P-QST to predict response to invasive treatment for painful CP and develop a predictive model for individualised prediction of treatment response for widespread use. This trial was approved by the University of Pittsburgh Institutional Review Board. Data and results will be reported and disseminated in conjunction with National Institutes of Health policies.

TRIAL REGISTRATION NUMBER

NCT04996628.

REKOVER study protocol: a pRospective patient treatment rEgistry of tramadol and dexKetoprofen trometamol oral fixed-dose combination (SKUDEXA) in mOderate to seVere acutE pain in Real-world setting in Asia

INTRODUCTION

Satisfactory management of acute pain remains a major medical challenge despite the availability of multiple therapeutic options including the fixed-dose combination (FDC) drugs. Tramadol and dexketoprofen trometamol (TRAM/DKP) 75/25 mg FDC was launched in 2018 in Asia and is widely used in the management of moderate to severe acute pain. There are limited data on its effectiveness and safety in Asian patients, and therefore, a need to better understand its usage patterns in clinical practice. We aim to understand the usage pattern of TRAM/DKP FDC, its effectiveness and tolerability in patients with moderate to severe acute pain in Asia.

METHODS AND ANALYSIS

REKOVER is a phase-IV, multicountry, multicentre, prospective, real-world observational study. A total of 750 postsurgical and non-surgical patients (male and female, aged 18-80 years) will be recruited from 13 tertiary-care hospitals (15 sites) in Singapore, Thailand, the Philippines and Malaysia. All patients prescribed with TRAM/DKP FDC and willing to participate in the study will be enrolled. The recruitment duration for each site will be 6 months. The severity of pain will be collected using Numeric Pain Rating Scale through the treatment period from day 1 to day 5, while satisfaction with the treatment will be evaluated using Patient Global Evaluation Scale at the end of treatment. Any adverse event reported during the study duration will be recorded for safety analysis (up to day 6). The study data will be entered into the ClaimIt portal and mobile application (app) (ObvioHealth, USA). All the inpatient data will be entered into the portal by the study site and for outpatient it will be done by patients through an app.

ETHICS AND DISSEMINATION

The study has been approved by the local ethics committee from each study sites in Singapore, Thailand, the Philippines and Malaysia. Findings will be disseminated through local and global conference presentations, publications in peer-reviewed scientific journals and continuing medical education.

Perceptions and experiences of paramedics managing people with non-traumatic low back pain: a qualitative study of Australian paramedics

BACKGROUND

Paramedics are often first providers of care to patients experiencing non-traumatic low back pain (LBP), though their perspectives and experiences with managing these cases remain unclear.

OBJECTIVES

This study explored paramedic views of the management of non-traumatic LBP including their role and experience with LBP management, barriers to referral and awareness of ambulance service guidelines.

DESIGN

Qualitative study using semistructured interviews conducted between January and April 2023.

SETTING

New South Wales Ambulance service.

PARTICIPANTS

A purposive sample of 30 paramedics of different specialities employed by New South Wales Ambulance were recruited.

RESULTS

Paramedic accounts demonstrated the complexity, challenge, frustration and reward associated with managing non-traumatic LBP. Paramedics perceived that their primary role focused on the assessment of LBP, and that calls to ambulance services were often driven by misconceptions surrounding the management of LBP, and a person's pain severity. Access to health services, patient factors, defensive medicine, paramedic training and education and knowledge of guidelines influenced paramedic management of LBP.

CONCLUSION

Paramedics often provide care to non-traumatic LBP cases yet depending on the type of paramedic speciality find these cases to be frustrating, challenging or rewarding to manage due to barriers to referral including access to health services, location, patient factors and uncertainty relating to litigation. Future research should explore patient perspectives towards ambulance service use for the management of their LBP.

Efficacy of epidural esketamine on postoperative sleep quality after laparoscopic and robotic lower abdominal surgeries: a study protocol for randomised, double-blind, controlled trial

INTRODUCTION

Postoperative sleep disturbances significantly impair postoperative recovery. The administration of intravenous esketamine has been shown to potentially improve postoperative sleep quality. However, the effectiveness of epidural esketamine in improving postoperative sleep quality remains to be elucidated. This study aims to explore the impact of both intraoperative and postoperative use of epidural esketamine on the postoperative sleep quality of patients undergoing minimally invasive lower abdominal surgeries.

METHODS AND ANALYSIS

This randomised, double-blind, parallel-group, placebo-controlled trial will be conducted at the Fudan University Shanghai Cancer Centre. A total of 128 adults undergoing minimally invasive lower abdominal surgeries will be randomly allocated in a 1:1 ratio to either the esketamine group or the placebo group. In the esketamine group, epidural esketamine will be administered intraoperatively (0.2 mg/kg) and postoperatively (25 mg). Postoperatively, all patients will receive epidural analgesia. The primary outcome of the study is the incidence of poor sleep quality on the third day after surgery. The sleep quality assessment will be conducted using the Pittsburgh Sleep Quality Index and a Numeric Rating Scale of sleep. The main secondary outcomes include postoperative pain and anxiety and depression scores. The postoperative pain, both rest pain and movement pain, will be assessed using a Numerical Rating Scale within 5 days after surgery. Anxiety and depression scores will be evaluated using the Hospital Anxiety and Depression Scale both before and after the surgery. Safety outcomes will include delirium, fidgeting, hallucinations, dizziness and nightmares. The analyses will be performed in accordance with intention-to-treat principle ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Ethics Committee of the Shanghai Cancer Centre (2309281-9). Prior to participation, all patients will provide written informed consent. The results of the trial are intended to be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2300076862.

Non-pharmacological therapies for pain management in paediatric intensive care units: a protocol for a scoping review

INTRODUCTION

In critically ill children, pain management is complex owing to cognitive development and the nature of hospitalisation in paediatric intensive therapy units. Although there are many protocols and guidelines for pain control via pharmacological interventions, non-pharmacological practices should also be explored and disseminated for their potential benefit.

METHODS AND ANALYSIS

A systematic literature search will be performed using the following databases: Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Excerpta Medica Database, Virtual Health Library, Medical Literature Analysis and Retrieval System Online, ScienceDirect, Scopus, Web of Science Core Collection, Theses from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Dart Europe, Open Access Theses and Dissertations and grey literature from Google Scholar. The research will consider quantitative and qualitative studies, mixed-method studies, systematic reviews, text articles, opinion articles, letters to editors and editorials in any language and from any database. The following will be eligible for inclusion: (1) newborns, infants, children and adolescents; and (2) non-pharmacological therapies used for pain in paediatric intensive care.

ETHICS AND DISSEMINATION

This study does not require ethical approval. The results of this research will be disseminated through social media channels and podcasts about pain in children.

TRIAL REGISTRATION NUMBER

This protocol has been registered with the Open Science Framework (DOI 10.17605/OSF.IO/DZHKT).

Effectiveness of musculoskeletal manipulations in patients with neck pain: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Neck pain is a common problem that severely affects physical and mental health. While musculoskeletal manipulations are recommended as the first-line treatment for adults with neck pain, the comparative effectiveness of different musculoskeletal manipulations remains unclear. This systematic review and network meta-analysis of randomised controlled trials (RCTs) will compare the effectiveness of different types of musculoskeletal manipulations, with the overarching aim of guiding clinical practice.

METHODS AND ANALYSIS

Two independent reviewers will search four English electronic databases (Web of Science, Cochrane Library, EMBASE, PubMed) and three Chinese electronic databases (China National Knowledge Infrastructure, China Science and Technology Journal Database, Wanfang) for relevant RCTs published from 1 January 2013 to 30 April 2023. The Clinical Trials Registry (ClinicalTrials.gov) will be searched for completed but unpublished RCTs. English and Chinese will be used to search English databases and Chinese databases, respectively. RCTs of musculoskeletal manipulations for adults (aged ≥18 years) with neck pain will be considered eligible for inclusion. A pairwise meta-analysis and network meta-analysis will be performed, and pooled risk ratios, standardised mean differences and 95% CIs will be determined.

ETHICS AND DISSEMINATION

Ethics approval is not required as this study is a literature review. The results of this review will be published in peer-reviewed journals or disseminated at conferences.

PROSPERO REGISTRATION NUMBER

CRD42023420775.

Balancing between being the most valuable player (MVP) and passing the ball: a qualitative study of support when living with chronic pain in Sweden

OBJECTIVE

This study aimed to elucidate the meaning of lived experiences of support from social networks and the healthcare sector in persons with chronic pain.

DESIGN

A qualitative, phenomenological hermeneutic method was used to analyse interview data.

SETTING

Participants were recruited from patient organisations in Sweden.

PARTICIPANTS

Ten (seven women, two men and one non-binary) individuals with chronic musculoskeletal pain were included.

FINDINGS

The meaning of lived experiences of support in persons with chronic pain involves balancing between being the most valuable player (MVP) and passing the ball, meaning balancing between being a capable person and accepting support to be that capable person.

CONCLUSION

For participants who lived with chronic pain, support means balancing between being capable (the MVP) and willing to accept support (passing the ball), which aligns with the concept of person-centred care. Our findings may be useful for policy-makers, managers and clinical professionals when planning and performing care for persons with chronic pain. Future research should focus on how the healthcare sector can create support to enable persons with chronic pain to be the MVP while being able to pass the ball to their social networks and the healthcare sector.

Combination of a propofol emulsion with alpha-2 adrenergic receptor agonists used for multimodal analgesia or sedation in intensive care units: a physicochemical stability study

OBJECTIVES

To assess the physicochemical stability of the combination of a propofol emulsion with an alpha-2 (α2) adrenergic receptor agonist (α2A; clonidine or dexmedetomidine) under conditions mimicking routine practice in an intensive care unit or in multimodal analgesia procedures.

METHODS

We developed and validated three stability-indicating methods based on high-performance liquid chromatography with ultraviolet (HPLC-UV) detection. Eight different conditions per combination were evaluated in triplicate, with variations in the simulated, bodyweight-adjusted dose level and the drugs' flow rate. The drugs were mixed in clinically relevant concentrations and proportions and then stored unprotected from light, in clear glass vials at room temperature for 96 hours. At each sampling point, we assessed the chemical stability (the HPLC-UV drug level, pH, and osmolality) and physical compatibility (visual aspect, zeta potential (ZP), mean droplet diameter (MDD, Z-average) and polydispersity index (PDI)). We validated our stability findings in positive and negative control experiments.

RESULTS

Over the 96-hour test, the concentrations of propofol, clonidine and dexmedetomidine did not fall below 90% of the initial value, and the pH and osmolality were stable. The visual aspect of the mixed propofol emulsions did not change. The MDD remained below 500 nm (range 165-195 nm). The PDI was always below 0.4; 78.7% of the measurements were below 0.1 and 21.3% were between 0.1 and 0.4. The ZP measurements (-31.3 to -42.9 mV) suggested that the emulsion was stable. The MDD and PDI increased slightly at 96 hours under some conditions, which might indicate early destabilisation of the emulsion. Given that the MDD remained below 500 nm, these emulsions are compatible with intravenous administration.

CONCLUSIONS

Our results demonstrate the chemical and physical compatibility of propofol-α2 agonist mixtures at concentrations and in proportions representative of standard protocols when stored unprotected from light at room temperature for 96 hours.

Effects of 6 weeks of cryotherapy plus compression therapy after total or unicompartmental knee arthroplasty: protocol for a single-centre, single-blind randomised controlled trial

INTRODUCTION

Effective rehabilitation after total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is often impeded by pain and swelling. Beneficial short-term effects in terms of pain and opioid use after a short period of cryotherapy (±compression therapy) have been demonstrated. The effectiveness of a longer intervention period on longer-term postoperative outcomes is unclear. This study aims to assess the effects of 6 weeks of cryotherapy plus compression therapy on pain, functioning and patient satisfaction after TKA or UKA.

METHODS AND ANALYSIS

A single-centre, single-blind randomised controlled trial will be conducted at a teaching hospital in the Netherlands. Patients over age 18 with end-stage osteoarthritis planned for a TKA or UKA are eligible; 104 UKA and 104 TKA patients will be included. Both groups will be randomly allocated (1:1) into an intervention group receiving 6 weeks of cryotherapy plus compression therapy (commencing after discharge from hospital) or a control group (usual care). The primary endpoint is perceived pain at rest at 6 weeks postoperatively. Secondary outcomes include compliance with cold protocol, pain at rest during the first six postoperative weeks and at 6 and 12 months postoperatively, pain on weight bearing, opioid use, functioning, patient satisfaction and complications.

ETHICS AND DISSEMINATION

The local medical ethics committee MEC-U approved the study protocol (R22.095/NL-number NL81956.100.22). The study will be conducted in accordance with the Declaration of Helsinki and Good Clinical Practice regulations, and personal data will be handled in agreement with the Dutch Personal Data Protection Act (AGV). Written informed consent will be obtained prior to performing any of the study procedures. We will disseminate study results through multiple peer-reviewed publications and through conference presentations.

TRIAL REGISTRATION NUMBER

NCT05572359.

Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol

BACKGROUND

Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain and analgesic medications may be risk factors for delirium. Delirium is associated with longer length of stay or cognitive impairment. Our systematic review and meta-analysis will examine the relationship between pain or analgesic medications with delirium occurrence, duration and severity among critically ill adults.

METHODS AND ANALYSIS

MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials and a review of recent conference abstracts will be searched without restriction from inception to 15 May 2023. Study inclusion criteria are: (1) age≥18 years admitted to intensive care; (2) report a measure of pain, analgesic medications and delirium; (3) study design-randomised controlled trial, quasiexperimental designs and observational cohort and case-control studies excluding case reports. Study exclusion criteria are: (1) alcohol withdrawal delirium or delirium tremens; or (2) general anaesthetic emergence delirium; or (3) lab or animal studies. Risk of bias will be assessed with the Risk of Bias V.2 and risk of bias in non-randomised studies tools. There is no language restriction. Occurrence estimates will be transformed using the Freeman-Tukey double arcsine. Point estimates will be pooled using Hartung-Knapp Sidik-Jonkman random effects meta-analysis to estimate a pooled risk ratio. Statistical heterogeneity will be estimated with the I2 statistic. Risk of small study effects will be assessed using funnel plots and Egger test. Studies will be analysed for time-varying and unmeasured confounding using E values.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is an analysis of published aggregated data. We will share our findings at conferences and in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

The finalised protocol was submitted to the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022367715).

Effectiveness of patients' involvement in a medical and nursing pain education programme: a protocol for an open-label randomised controlled trial including qualitative data

INTRODUCTION

Pain is a multidimensional experience that varies among individuals and has a significant impact on their health. A biopsychosocial approach is recommended for effective pain management; however, health professionals' education is weak on this issue. Patient involvement is a promising didactic methodology in developing a more holistic perspective, however there is a lack of reliable evidence on this topic. The aim of the present study is to evaluate the effectiveness of patient involvement in pain education in undergraduate medicine and nursing students.

METHODS AND ANALYSIS

An open-label randomised controlled trial including qualitative data will be conducted. After an introductory lesson, each student will be randomly assigned to the intervention group, which includes an educational session conducted by a patient-partner along with an educator, or to the control group in which the session is exclusively conducted by an educator. Both sessions will be carried out according to the Case-Based Learning approach. Primary outcomes will be students' knowledge, attitudes, opinions and beliefs about pain management, whereas the secondary outcome will be students' satisfaction. The Pain Knowledge and Attitudes (PAK) and Chronic Pain Myth Scale (CPMS) will be administered preintervention and postintervention to measure primary outcomes. Students' satisfaction will be measured by a questionnaire at the end of the session. Two focus groups will be conducted to evaluate non-quantifiable aspects of learning.

ETHICS AND DISSEMINATION

The protocol of this study was approved by the independent Area Vasta Emilia Nord ethics committee.Adherence to The Declaration of Helsinki and Good Clinical Practice will ensure that the rights, safety and well-being of the participants in the study are safeguarded, as well as data reliability. The results will be disseminated through scientific publications and used to improve the educational offer. A version of the anonymised data set will be released for public access.

TRIAL REGISTRATION

Trial was not registered on ClinicalTrials.gov as the interventions being compared only concern educational programmes and the outcomes considered do not refer to any clinical dimension.

A qualitative longitudinal study of traumatic orthopaedic injury survivors' experiences with pain and the long-term recovery trajectory

OBJECTIVES

To explore trauma patients' experiences of the long-term recovery pathway during 18 months following hospital discharge.

DESIGN

Longitudinal qualitative study.

SETTING AND PARTICIPANTS

Thirteen trauma patients with injuries associated with pain that had been interviewed 6 weeks after discharge from Oslo University Hospital in Norway, were followed up with an interview 18 months postdischarge.

METHOD

The illness trajectory framework informed the data collection, with semistructured, in-depth interviews that were analysed thematically.

RESULTS

Compared with the subacute phase 6 weeks postdischarge, several participants reported exacerbated mental and physical health, including increased pain during 18 months following discharge. This, andalternating periods of deteriorated health status during recovery, made the pathway unpredictable. At 18 months post-discharge, participants were coping with experiences of reduced mental and physical health and socioeconomic losses. Three main themes were identified: (1) coping with persistent pain and reduced physical function, (2) experiencing mental distress without access to mental healthcare and (3) unmet needs for follow-up care. Moreover, at 18 months postdischarge, prescribed opioids were found to be easily accessible from GPs. In addition to relieving chronic pain, motivations to use opioids were to induce sleep, reduce withdrawal symptoms and relieve mental distress.

CONCLUSIONS AND IMPLICATIONS

The patients' experiences from this study establish knowledge of several challenges in the trauma population's recovery trajectories, which may imply that subacute health status is a poor predictor of long-term outcomes. Throughout recovery, the participants struggled with physical and mental health needs without being met by the healthcare system. Therefore, it is necessary to provide long-term follow-up of trauma patients' health status in the specialist health service based on individual needs. Additionally, to prevent long-term opioid use beyond the subacute phase, there is a need to systematically follow-up and reassess motivations and indications for continued use throughout the recovery pathway.

Efficacy of a physiotherapy, yoga and patient education programme for patients with breast cancer and hormone therapy-induced pain: a multicentre randomised study protocol (SKYPE 2)

INTRODUCTION

Osteoarticular pain is experienced by approximately 50% of patients with breast cancer under hormone therapy and can increase the risk of therapy discontinuation. Among complementary therapies, yoga has shown efficacy regarding reduction of fatigue, anxiety, pain due to hormone therapy and inflammation. Personalised patient education programmes increase engagement and motivation, and induce effective behavioural changes. The SKYPE programme, an integrated intervention combining physiotherapy, yoga and patient education, showed promising efficacy on hormone therapy-induced pain in a previous pilot study. In this study, we hypothesised that using theory-based patient education favour learning and practising 15 min of at-home yoga every day to decrease hormone therapy-induced pain.

METHODS AND ANALYSIS

This multicentre randomised study will assess the efficacy of the SKYPE programme on pain reduction compared with standard care in patients with breast cancer reporting osteoarticular pain due to hormone therapy. Main secondary objectives will describe pain evolution and characteristics, patient adhesion to yoga sessions and home practice, forward flexibility, quality of life, fatigue, anxiety and compliance to hormone therapy. Patients in the intervention group will participate in 1 weekly educational yoga session of 90 min for 6 weeks, supervised by physiotherapists (period 1). They will also perform daily at-home 15 min yoga sessions for 12 weeks, the total duration of the intervention (periods 1 and 2). Pain will be evaluated during physiotherapy check-ups at baseline (T0), at 6 weeks (T1) and at 12 weeks (T2).

ETHICS AND DISSEMINATION

This study was approved by the ethics committee (CPP Ile de France 8 on 22 June 2020). The results will be disseminated to patients and healthcare professionals, and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04457895.

Effect of extracorporeal shock wave combined with Kinesio taping on upper limb function during individuals with biceps brachii tendinopathy：protocol for a double-blind, randomised controlled trial

INTRODUCTION

Long head of biceps brachii tendinopathy (LHBT) is characterised by persistent pain and disability of shoulder joint, impairing patients' quality of life. Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment, which promotes tissue regeneration and repair. However, ESWT has a side effect that often causes short-term pain and swelling in the treatment area. It is known that the effects of Kinesio taping (KT) on relieving swelling and pain. Due to insufficient clinical evidence from current limited studies, this randomised controlled study aims to explore the effects of ESWT combined with KT on upper limb function during individuals with LHBT.

METHODS AND ANALYSIS

A 2×2 factorial design, double-blind, randomised controlled trial will be conducted. A total of 144 participants will be randomly allocated into one of four groups (KT+ESWT, KT+sham ESWT, sham KT+ESWT or sham KT+sham ESWT) to participate in a 4-week treatment programme. Measurements will be taken at pretreatment (baseline), immediately after treatment and 6 weeks after treatment. The primary endpoint will be the Constant-Murley score (CMS), the secondary endpoints will include the pain Numerical Rating Scale, range of motion, pressure pain threshold and soft tissue hardness of biceps, speed test and global rating of change. Repeated measures analysis of variance will be used to compare differences among the effects of different interventions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. In addition to international conference reports, findings will be disseminated through international publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100051324.

Switching anti-CGRP monoclonal antibodies in chronic migraine: real-world observations of erenumab, fremanezumab and galcanezumab

OBJECTIVES

The anti-calcitonin gene-related peptide monoclonal antibodies (anti-CGRP-mAb) are effective in migraine; however, few studies have examined the benefit of switching from one anti-CGRP-mAb to another. In order to better inform clinical practice in this situation, we present our real-world findings of switching anti-CGRP-mAb in chronic migraine.

METHODS

Individuals with chronic migraine that switched anti-CGRP-mAb treatment (erenumab, fremanezumab or galcanezumab) due to ineffectiveness or adverse effects were retrospectively identified. Headache diary data before and up to 6 months after anti-CGRP-mAb switch were analysed. Main outcome measures were monthly red days (days with headaches limiting activity or requiring triptans), headache days (days with any kind of headache), triptan use, other analgesic use and headache disability (Headache Impact Test-6 (HIT-6) score) at 3 months.

RESULTS

The analysis included 66 instances of switching among 54 individuals. There were non-significant reductions of -1.2 (-2.7, 0.3) red days from baseline at 3 months, with 10 individuals (15%) showing ≥50% improvement and 22 (33%) experiencing a ≥30% improvement. Improvements in headache days, triptan days, other painkiller use and HIT-6 score were non-significant. When individuals that switched due to side effects were excluded from the analysis, significant reductions in headache (Friedman p=0.044) and a trend for improvement in red days (Friedman p=0.083) were observed. With regard to side effects, on 12 occasions these improved or resolved on switching to a different anti-CGRP-mAb, while new symptoms were reported on eight occasions following a switch.

CONCLUSION

We recorded modest improvements in headache outcomes, although significant results were only observed in those that switched anti-CGRP-mAb due to ineffectiveness. Switching may therefore be a viable option for these individuals.

Cognitive function and its associated factors among patients with cancer pain: a multicentre cross-sectional study in China

OBJECTIVE

This research aimed to assess the levels of cognitive function and its contributing factors among individuals experiencing cancer pain (CP) in mainland China.

DESIGN

A descriptive, cross-sectional study.

SETTING

The investigation was undertaken within three tertiary oncology hospitals.

PARTICIPANTS

We included 220 hospitalised individuals who reported experiencing cancer-related pain and consented to complete the research questionnaires.

OUTCOME MEASURES

The collected data encompassed sociodemographic and clinical variables, augmented by results from validated questionnaires. Cognitive impairment (CI) was evaluated using the Functional Assessment of Cancer Therapy-Cognitive (FACT-Cog) scale, with scores ranging from 0 to 148. Sleep quality, depression and anxiety were assessed through the Pittsburgh Sleep Quality Index, the Patient Health Questionnaire-9 and the Generalised Anxiety Disorder-7, respectively. A binary logistic regression model was used to identify factors associated with CI in individuals with CP.

RESULTS

Of the 225 individuals approached, 220 (97.8%) participated in the study. The mean FACT-Cog score for those with CP was 101.29 (SD=25.24; range=25-148). The prevalence of CI among these individuals was 35.90%. Sleep quality was rated below medium in 45% of participants with CP. More than moderate pain was reported by 28.2%, with 64.6% experiencing depression and 38.6% experiencing anxiety. Increased odds of developing CI were observed in those with CP (OR 1.422, 95% CI 1.129 to 1.841), depression (OR 1.119, 95% CI 1.029 to 1.2117), anxiety (OR 1.107, 95% CI 1.005 to 1.220), advancing age (OR 1.042, 95% CI 1.013 to 1.073), poor sleep quality (OR 1.126, 95% CI 1.013 to 1.252) and a history of smoking (OR 3.811, 95% CI 1.668 to 8.707).

CONCLUSIONS

CI associated with CP is notably prevalent in China. Those older, with a smoking history, inadequate sleep, more severe pain, depression and anxiety, have a heightened risk of CI. Consequently, interventions need to be personalised, addressing these key determinants.

Cannabis for medical use versus opioids for chronic non-cancer pain: a systematic review and network meta-analysis of randomised clinical trials

OBJECTIVE

The objective of this study is to evaluate the comparative benefits and harms of opioids and cannabis for medical use for chronic non-cancer pain.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

EMBASE, MEDLINE, CINAHL, AMED, PsycINFO, PubMed, Web of Science, Cannabis-Med, Epistemonikos and the Cochrane Library (CENTRAL) from inception to March 2021.

STUDY SELECTION

Randomised trials comparing any type of cannabis for medical use or opioids, against each other or placebo, with patient follow-up ≥4 weeks.

DATA EXTRACTION AND SYNTHESIS

Paired reviewers independently extracted data. We used Bayesian random-effects network meta-analyses to summarise the evidence and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to evaluate the certainty of evidence and communicate our findings.

RESULTS

Ninety trials involving 22 028 patients were eligible for review, among which the length of follow-up ranged from 28 to 180 days. Moderate certainty evidence showed that opioids provide small improvements in pain, physical functioning and sleep quality versus placebo; low to moderate certainty evidence supported similar effects for cannabis versus placebo. Neither was more effective than placebo for role, social or emotional functioning (all high to moderate certainty evidence). Moderate certainty evidence showed there is probably little to no difference between cannabis for medical use and opioids for physical functioning (weighted mean difference (WMD) 0.47 on the 100-point 36-item Short Form Survey physical component summary score, 95% credible interval (CrI) -1.97 to 2.99), and cannabis resulted in fewer discontinuations due to adverse events versus opioids (OR 0.55, 95% CrI 0.36 to 0.83). Low certainty evidence suggested little to no difference between cannabis and opioids for pain relief (WMD 0.23 cm on a 10 cm Visual Analogue Scale (VAS), 95% CrI -0.06 to 0.53) or sleep quality (WMD 0.49 mm on a 100 mm VAS, 95% CrI -4.72 to 5.59).

CONCLUSIONS

Cannabis for medical use may be similarly effective and result in fewer discontinuations than opioids for chronic non-cancer pain.

PROSPERO REGISTRATION NUMBER

CRD42020185184.

Meeting high-risk patient pain care needs through intensive primary care: a secondary analysis

OBJECTIVE

Chronic pain disproportionately affects medically and psychosocially complex patients, many of whom are at high risk of hospitalisation. Pain prevalence among high-risk patients, however, is unknown, and pain is seldom a focus for improving high-risk patient outcomes. Our objective is to (1) evaluate pain frequency in a high-risk patient population and (2) identify intensive management (IM) programme features that patients and providers perceive as important for promoting patient-centred pain care within primary care (PC)-based IM.

DESIGN

Secondary observational analysis of quantitative and qualitative evaluation data from a multisite randomised PC-based IM programme for high-risk patients.

SETTING

Five integrated local Veterans Affairs (VA) healthcare systems within distinct VA administrative regions.

PARTICIPANTS

Staff and high-risk PC patients in the VA.

INTERVENTION

A multisite randomised PC-based IM programme for high-risk patients.

OUTCOME MEASURES

(a) Pain prevalence based on VA electronic administrative data and (b) transcripts of interviews with IM staff and patients that mentioned pain.

RESULTS

Most (70%, 2593/3723) high-risk patients had at least moderate pain. Over one-third (38%, 40/104) of the interviewees mentioned pain or pain care. There were 89 pain-related comments addressing IM impacts on pain care within the 40 interview transcripts. Patient-identified themes were that IM improved communication and responsiveness to pain. PC provider-identified themes were that IM improved workload and access to expertise. IM team member-identified themes were that IM improved pain care coordination, facilitated non-opioid pain management options and mitigated provider compassion fatigue. No negative IM impacts on pain care were mentioned.

CONCLUSIONS

Pain is common among high-risk patients. Future IM evaluations should consider including a focus on pain and pain care, with attention to impacts on patients, PC providers and IM teams.

Effects of transcranial direct current stimulation combined with Pilates-based exercises in the treatment of chronic low back pain in outpatient rehabilitation service in Brazil: double-blind randomised controlled trial protocol

INTRODUCTION

Chronic low back pain may be associated with pathoanatomical, neurophysiological, physical, psychological and social factors; thus, treatments to reduce symptoms are important to improve the quality of life of this population. We aimed to evaluate the effects of transcranial direct current stimulation (tDCS) combined with Pilates-based exercises compared with sham stimulation on pain, quality of life and disability in patients with chronic non-specific low back pain.

METHODS AND ANALYSIS

This is a protocol for a double-blind randomised controlled trial with participants, outcome assessor and statistician blinded. We will include 36 individuals with a history of non-specific chronic low back pain for more than 12 weeks and minimum pain intensity of 3 points on the Numerical Pain Rating Scale. Individuals will be randomised into two groups: (1) active tDCS combined with Pilates-based exercises and (2) sham tDCS combined with Pilates-based exercises. Three weekly sessions of the protocol will be provided for 4 weeks, and individuals will be submitted to three assessments: the first (T0) will be performed before the intervention protocol, the second (T1) immediately after the intervention protocol and the third (T2) will be a follow-up 1 month after the end of the intervention. We will assess pain, disability, central sensitisation, quality of life, pressure pain threshold, global impression of change, adverse events and medication use. The Numerical Pain Rating Scale and the Roland-Morris Disability Questionnaire will be used at T1 to assess pain and disability, respectively, as primary outcome measures.

ETHICS AND DISSEMINATION

This trial was prospectively registered in ClinicalTrials.gov website and ethically approved by the Ethics and Research Committee of the Faculty of Health Sciences of Trairi (report number: 5.411.244) before data collection. We will publish the results in a peer-reviewed medical journal and on institution websites.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT05467566).

Knowledge and practice of nurses with respect to perioperative hypothermia prevention in the Northwest Amhara Regional State Referral Hospitals, Ethiopia: a cross-sectional study

OBJECTIVES

It has been reported that maintaining a normal body temperature among surgical patients can reduce the length of hospitalisation by up to 40%, decrease the risk of surgical site infection by 64% and reduce mortality by fourfold. Nurses are primarily responsible for preventing the occurrence of hypothermia among surgical patients. This study assessed nurses' knowledge and practices with respect to perioperative hypothermia prevention in Northwest Ethiopia, and investigated the factors associated with good knowledge and practice.

DESIGN

Cross-sectional study.

SETTING

Northwest Amhara Regional State Referral Hospitals, Northwest Ethiopia, 25 March-20 May 2021.

PARTICIPANTS

413 nurses working in the perioperative units of five referral hospitals.

OUTCOME MEASURES

Perioperative hypothermia prevention knowledge and practice among nurses.

RESULTS

Nearly three-fifths (59.1%; 95% CI: 54.7% to 63.7%) of respondents had good knowledge and about half (50.4%; 95% CI: 45.5% to 55.0%) had good practice with respect to perioperative hypothermia prevention. Factors associated with nurses' knowledge of prevention of perioperative hypothermia included male sex (adjusted OR (AOR): 1.61, 95% CI: 1.02 to 2.53), having a bachelor's degree (AOR: 2.50, 95% CI: 1.25 to 5.00), having a master's degree (AOR: 4.39, 95% CI: 1.45 to 13.20) and training participation (AOR: 3.68, 95% CI: 2.14 to 6.33). Factors associated with nurses' practice of prevention of perioperative hypothermia included working in recovery (AOR: 2.87, 95% CI: 1.08 to 7.58) and intensive care units (AOR: 2.39, 95% CI: 1.09 to 5.22), training participation (AOR: 2.64, 95% CI: 1.53 to 4.57), being satisfied with their job (AOR: 2.15, 95% CI: 1.34 to 3.43) and having good knowledge (AOR: 2.64, 95% CI: 1.63 to 4.27).

CONCLUSION

Nurses' knowledge and practice of the prevention of perioperative hypothermia were inadequate. Hospital managers need to design and strengthen training programmes and work to enhance job satisfaction.

Optimal concentration of ropivacaine for peripheral nerve blocks in adult patients: a protocol for systematic review and meta-analysis

INTRODUCTION

Ropivacaine is the most widely used local anaesthetic for peripheral nerve blocks (PNBs). The effects of various concentrations of ropivacaine in PNB have been investigated and compared by many randomised controlled trials (RCTs). This protocol aims to identify the optimal concentration of ropivacaine for PNB in adult patients.

METHODS AND ANALYSIS

PubMed, EMBASE, the Cochrane library and Web of Science will be searched from their inception to 10 July 2023. RCTs that compare the analgesic effects of different concentrations of ropivacaine for PNB will be included. Retrospective studies, meta-analyses, reviews, case reports, letters, conference abstracts and paediatric studies will be excluded. The duration of analgesia will be named as the primary outcome. Secondary outcomes will include the onset time of motor and sensory blockade, postoperative pain scores, analgesic requirements over 24 hours and the incidence of adverse effects. The study selection, data extraction and quality assessment will be performed by two independent reviewers. Data processing and analysis will be performed by RevMan 5.4. The quality of the evidence will be assessed by the Grading of Recommendations Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethical approval is not applicable. The results of this study will be submitted to peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42023406362.

Effect of whole-body cryotherapy versus placebo cryotherapy on joint pain induced by aromatase inhibitors in women with early stage breast cancer: a randomised clinical trial

INTRODUCTION

Hormone therapy (HT) is a major adjuvant treatment for breast cancer. Despite their effectiveness, aromatase inhibitors can cause several side effects, including arthralgia in 35%-50% of patients. These side effects frequently lead to the premature discontinuation of HT. Whole-body cryotherapy (WBC) can be used for managing arthritic pain. The primary objective of this study will be to evaluate the effect of WBC on aromatase-induced joint pain, compared with placebo cryotherapy, in patients with hormone-dependent breast cancer receiving adjuvant aromatase inhibitors. The secondary objectives will be to evaluate WBC safety and its effect on analgesic consumption, HT adherence and quality of life.

METHODS AND ANALYSIS

In this randomised, placebo-controlled, double-blinded clinical trial, 56 patients with aromatase inhibitor-induced joint pain and a Brief Pain Inventory-Short Form (BPI-SF) score ≥3 for the worst pain experienced in the previous week will be randomised into the WBC or placebo cryotherapy arm (10 sessions in each group). The primary outcome will be the BPI-SF score at week 6 post-treatment. The secondary outcomes will include the BPI-SF scores at months 3 and 6 post-treatment, the BPI-SF pain severity index and pain interference index, the Health Assessment Questionnaire score, the number of days of aromatase inhibitor treatment and analgesic consumption in the 15 days before the visits at week 6 and months 3 and 6 after cryotherapy. The incidence of adverse events will also be investigated.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee Est IV of Hospital Civil, Strasbourg, France. Protocol V.5 was approved in December 2022. The results will be disseminated in a peer-reviewed journal and presented at international congresses.

TRIAL REGISTRATION NUMBER

NCT05315011.

Trends in the treatment of fibromyalgia in South Korea between 2011 and 2018: a retrospective analysis of cross-sectional health insurance data

OBJECTIVES

Fibromyalgia treatment trends vary globally; however, the trend in South Korea has not been investigated yet. This study aimed to analyse the fibromyalgia treatment trends in South Korea.

DESIGN

Retrospective, observational study using serial cross-sectional data.

SETTING

The National Patient Samples of the Korean Health Insurance Review & Assessment Service from 2011 to 2018 were used.

PARTICIPANTS

A total of 31 059 patients with fibromyalgia were included in this study. The basic characteristics of the patients were stratified by sex, age and comorbidity. A patient was considered to have a condition if it was recorded as a principal diagnosis at least once in a year.

PRIMARY AND SECONDARY OUTCOME MEASURES

Trends in the types of medical visits and prescribed treatments were investigated and the values are presented as rates per 100 patients. The types of pharmacological treatment were presented according to the existing clinical guidelines. Additionally, combination prescription trends and associated characteristics were investigated.

RESULTS

Of the patients, 66.2% were female. Visits to internal medicine departments showed the most significant increase (2011: 11.34; 2018: 21.99; p<0.001). Non-pharmacological treatment rates declined (physical therapy 2011: 18.11; 2018: 13.69; p<0.001, acupuncture 2011: 52.03; 2018: 30.83; p<0.001). Prescription rates increased for analgesics, relaxants, antiepileptics and antidepressants. Non-steroidal anti-inflammatory drug prescriptions had the highest increase (2011: 27.65; 2018: 40.02; p<0.001). Serotonin-norepinephrine reuptake inhibitor prescriptions showed significant growth (2011: 2.4; 2018: 8.05; p<0.001). Prescription durations were generally longer for women (p<0.001), with higher rate increases in this group. Combinations of ≥3 medication classes increased (2011: 8.2; 2018: 9.64; p=0.041). Women were more likely to receive combination prescriptions (crude OR 1.47 (95% CI 1.29 to 1.68), adjusted 1.18 (95% CI 1.03 to 1.36)).

CONCLUSIONS

Our findings provide basic reference data for the development and application of national guidelines for fibromyalgia.

Palliative care interventions for patients with head and neck cancer: protocol for a scoping review

INTRODUCTION

A head and neck cancer (HNC) diagnosis significantly impacts a patient's quality of life (QOL). Palliative care potentially improves their QOL. We will conduct a scoping review to identify existing knowledge about palliative care interventions for patients with HNC.

METHODS AND ANALYSIS

This scoping review was designed in accordance with the JBI Manual for Evidence Synthesis: Scoping Reviews and will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Our eligibility criteria follow the Population, Intervention, Comparison or Control, Outcomes and Study characteristics framework. The population is adult patients with locally advanced, metastatic, unresectable and/or recurrent HNC. We include peer-reviewed journal articles and articles in the press, in English, reporting on palliative care interventions with at least two of the eight National Consensus Project on Clinical Practice Guidelines for Quality Palliative Care domains; studies with and without comparators will be included. The outcomes are patient QOL (primary) and symptom severity, patients' satisfaction with care, patients' mood, advance care planning and place of death (secondary). We developed a search strategy across ten databases, to be searched from the inception to 11 September 2023: Medline ALL (Medline and EPub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase Classic+Embase, Emcare and PsycINFO all from the OvidSP platform; CINAHL from EBSCOhost, Scopus from Elsevier, Web of Science from Clarivate and Global Index Medicus from WHO. We will extract data using a piloted data form and analyse the data through descriptive statistics and thematic analysis.

ETHICS AND DISSEMINATION

Ethics approval is not needed for a scoping review. We will disseminate the findings to healthcare providers and policy-makers by publishing the results in a scientific journal.

Feasibility interventional study investigating PAIN in neurorehabilitation through wearabLE SensorS (PAINLESS): a study protocol

INTRODUCTION

Millions of people survive injuries to the central or peripheral nervous system for which neurorehabilitation is required. In addition to the physical and cognitive impairments, many neurorehabilitation patients experience pain, often not widely recognised and inadequately treated. This is particularly true for multiple sclerosis (MS) patients, for whom pain is one of the most common symptoms. In clinical practice, pain assessment is usually conducted based on a subjective estimate. This approach can lead to inaccurate evaluations due to the influence of numerous factors, including emotional or cognitive aspects. To date, no objective and simple to use clinical methods allow objective quantification of pain and the diagnostic differentiation between the two main types of pain (nociceptive vs neuropathic). Wearable technologies and artificial intelligence (AI) have the potential to bridge this gap by continuously monitoring patients' health parameters and extracting meaningful information from them. Therefore, we propose to develop a new automatic AI-powered tool to assess pain and its characteristics during neurorehabilitation treatments using physiological signals collected by wearable sensors.

METHODS AND ANALYSIS

We aim to recruit 15 participants suffering from MS undergoing physiotherapy treatment. During the study, participants will wear a wristband for three consecutive days and be monitored before and after their physiotherapy sessions. Measurement of traditionally used pain assessment questionnaires and scales (ie, painDETECT, Doleur Neuropathique 4 Questions, EuroQoL-5-dimension-3-level) and physiological signals (photoplethysmography, electrodermal activity, skin temperature, accelerometer data) will be collected. Relevant parameters from physiological signals will be identified, and AI algorithms will be used to develop automatic classification methods.

ETHICS AND DISSEMINATION

The study has been approved by the local Ethical Committee (285-2022-SPER-AUSLBO). Participants are required to provide written informed consent. The results will be disseminated through contributions to international conferences and scientific journals, and they will also be included in a doctoral dissertation.

TRIAL REGISTRATION NUMBER

NCT05747040.

Predictors of outcome in sciatica patients following an epidural steroid injection: the POiSE prospective observational cohort study protocol

INTRODUCTION

Sciatica can be very painful and, in most cases, is due to pressure on a spinal nerve root from a disc herniation with associated inflammation. For some patients, the pain persists, and one management option is a spinal epidural steroid injection (ESI). The aim of an ESI is to relieve leg pain, improve function and reduce the need for surgery. ESIs work well in some patients but not in others, but we cannot identify these patient subgroups currently. This study aims to identify factors, including patient characteristics, clinical examination and imaging findings, that help in predicting who does well and who does not after an ESI. The overall objective is to develop a prognostic model to support individualised patient and clinical decision-making regarding ESI.

METHODS

POiSE is a prospective cohort study of 439 patients with sciatica referred by their clinician for an ESI. Participants will receive weekly text messages until 12 weeks following their ESIand then again at 24 weeks following their ESI to collect data on leg pain severity. Questionnaires will be sent to participants at baseline, 6, 12 and 24 weeks after their ESI to collect data on pain, disability, recovery and additional interventions. The prognosis for the cohort will be described. The primary outcome measure for the prognostic model is leg pain at 6 weeks. Prognostic models will also be developed for secondary outcomes of disability and recovery at 6 weeks and additional interventions at 24 weeks following ESI. Statistical analyses will include multivariable linear and logistic regression with mixed effects model.

ETHICS AND DISSEMINATION

The POiSE study has received ethical approval (South Central Berkshire B Research Ethics Committee 21/SC/0257). Dissemination will be guided by our patient and public engagement group and will include scientific publications, conference presentations and social media.

Exploring the postoperative pain experiences of individuals with opioid use disorder and the nurses providing care in the USA: A qualitative descriptive study protocol

INTRODUCTION

The goal of this study is to gain firsthand insights from individuals with a history of opioid use disorder (OUD) using medication for OUD on their experiences with postoperative pain care. This study also seeks to describe the experiences of nurses caring for individuals with OUD, and the challenges they may face managing complaints of pain in this population. Research suggests that hospitals can significantly enhance the quality of the care they deliver by investigating an individual's experience in the care setting. These insights will allow for the development of strategies for nurses to deepen their understanding of and, therefore, advocate and improve care for, this vulnerable and often stigmatised population.

METHODS AND ANALYSIS

A qualitative descriptive study will be conducted consisting of a prescreening and demographics questionnaire, and individual semistructured interviews with approximately 10-15 individuals with OUD having recently undergone surgery and 10-15 nurses providing care for this population for a total of 20-30 interviews. This approach involves the collection of separate but complementary data (ie, perceptions of individuals with OUD and nurses) concerning the phenomena of postoperative pain management. Sampling will continue until data saturation is reached. Descriptive statistics and thematic analysis will then be used. Reporting will adhere to the Standards for Reporting Qualitative Research checklist.

ETHICS AND DISSEMINATION

This study received approval from the Institutional Review Board at Northeastern University. Alongside peer-reviewed journal publications, the findings will be presented at relevant conferences, and a plain language summary will be distributed to the study participants.

rain connectivity-guided, Optimised theta burst transcranial magnetic stimulation to improve Central Pain Modulation in knee Osteoarthritis Pain (BoostCPM): protocol of a pilot randomised clinical trial in a secondary care setting in the UK

INTRODUCTION

Chronic pain is a common health problem that is not efficiently managed by standard analgesic treatments. There is evidence that treatment resistance may result from maladaptive brain changes in areas that are fundamental to the perception of pain. Knee osteoarthritis is one of the most prevalent causes of chronic pain and commonly associated with negative affect. Chronic knee osteoarthritis pain is also associated with altered right anterior insula functional connectivity. We posit that reversal of these brain circuit alterations may be critical to alleviate chronic pain and associated negative affect, and that this can be achieved through non-invasive neuromodulation techniques. Despite growing interest in non-invasive neuromodulation for pain relief and proven efficacy in depression, results in chronic pain are mixed with limited high-quality evidence for clinical and mechanistic efficacy. Limitations include patient heterogeneity, imprecision of target selection, uncertain blinding and protocols that may deliver pulses at subclinical efficacy.

METHODS AND ANALYSIS

We hence developed an optimised treatment protocol of connectivity-guided intermittent theta-burst stimulation (iTBS) targeting the left dorsolateral prefrontal cortex with accelerated delivery on four consecutive days (allowing 4 days within the same week as protocol variation) with five daily treatment sessions that will be piloted in a sham-controlled design in 45 participants with chronic knee pain. This pilot study protocol will assess feasibility, tolerability and explore mechanistic efficacy through serial functional/structural magnetic resonance imaging (MRI) and quantitative sensory testing.

ETHICS AND DISSEMINATION

This pilot trial has been approved by the Ethics Committee Cornwall and Plymouth.Results of the pilot trial will be submitted to peer-reviewed journals, presented at research conferences and may be shared with participants and PPI/E advisors.

TRIAL REGISTRATION NUMBER

ISRCTN15404076.

Strategies for reducing pain at dressing change in chronic wounds: protocol for a mapping review

INTRODUCTION

Although pain experienced at dressing change has been reported as the worst aspect of living with chronic wounds, UK guidance for their management is primarily tailored to wound healing and only attends to pain as a secondary consideration. Consequently, there is little up-to-date guidance that specifically addresses how patients, carers and healthcare professionals should manage wound-related pain at dressing change. This mapping review will identify, describe and appraise the existing research evidence for strategies used to assess pain intensity and prevent or alleviate pain at dressing change in chronic wounds. In addition, it will highlight areas for future research and inform the development of up-to-date guidance for healthcare professionals.

METHODS AND ANALYSIS

We will search MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily (via Ovid SP), Embase (via Ovid SP), Cochrane Central Register of Controlled Trials (via Wiley Cochrane Library), Cumulative Index of Nursing and Allied Health Literature (via EBSCO) and the Web of Science Citation Index Expanded and Social Sciences Citation Index (via Clarivate Analytics). Screening will be undertaken independently by two reviewers, with any disagreements resolved through discussion. Included studies will be subject to coding, using a tested data extraction tool, by two reviewers working independently. The methodological quality of the studies included will be reviewed using quality assessment instruments appropriate for each study design (Cochrane Risk of Bias tool (RoB 2); Risk of Bias in Non-randomised Studies of interventions tool; Critical Appraisal Skills Programme tool). Data will be described narratively and also presented visually in an interactive web-based evidence and gap map.

ETHICS AND DISSEMINATION

As this mapping review does not collect original data, ethical approval is not applicable. Findings will be disseminated via a written report, an interactive online mapping tool and in peer-reviewed journals and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021260130.

Experiences of misuse and symptoms of dependence among people who use gabapentinoids: a qualitative systematic review protocol

INTRODUCTION

Gabapentinoids are among the most widely prescribed pain medications. However, there is growing evidence to suggest that gabapentinoids may be associated with dependence and misuse. The aim of this systematic review is to synthesise the qualitative literature on gabapentinoid misuse and symptoms of dependence. The findings of this study will inform efforts to mitigate emerging harms.

METHODS AND ANALYSIS

A systematic review of qualitative research will explore lived experiences of misuse and symptoms of dependence among people who use gabapentinoids. Six databases (MEDLINE, Scopus, Web of Science, CINAHL, EMBASE and PsycINFO) and grey literature sources will be searched from inception to May 2023. Qualitative studies that include people with lived experiences of gabapentinoid misuse and symptoms of gabapentinoid dependence will be included. Reference lists of included studies will also be screened for additional studies. The methodological quality of included studies will be appraised using the Critical Appraisal Skills Programme qualitative checklist, and higher quality studies will be prioritised in the thematic synthesis. The GRADE-CERQual approach will be used to assess confidence in the overall findings of the review.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. The findings of this review will be disseminated in peer-reviewed journals, at conferences and on social media.

PROSPERO REGISTRATION NUMBER

CRD42023401832.

4A after access: a new mnemonic to aid timely administration of IV/IO treatment in trauma patients

Administration of medication is a well-established part of prehospital trauma care. Guidance varies on the types of recommended medications and when they should be administered. Mnemonics have become commonplace in prehospital medicine to facilitate recall and retention. However, there is no comprehensive aid for the administration of medication in trauma patients. We propose a new mnemonic for the delivery of relevant intravenous or intraosseous medications in trauma patients. A '4A after Access' approach should enhance memory recall for the efficient provision of patient care. These 4As are: antifibrinolysis, analgesia, antiemesis and antibiotics. This mnemonic is designed to be used as an optional aide memoire in conjunction with existing treatment algorithms in the military prehospital setting.

Exploring usual care for patients with low back pain in primary care: a cross-sectional study of general practitioners, physiotherapists and chiropractors

OBJECTIVES

To explore the elements and composition of care provided by general practitioners (GPs), physiotherapists (PTs) and chiropractors (DCs) to patients with low back pain (LBP).

DESIGN

Observational study.

SETTING

Primary care setting, Denmark.

PARTICIPANTS

Primary care clinicians (GPs, PTs and DCs) in the Region of Southern Denmark were invited to register consecutive adult patient visits with LBP as the primary complaint.

PRIMARY OUTCOME MEASURES

Clinicians reported care elements provided to patients with LBP. Elements varied due to professional differences (eg, prescriptive rights). Data were descriptively analysed, on group and individual levels, for frequency and combination of care elements, and practice patterns were explored with latent class analysis.

RESULTS

The clinicians (33 GPs, 67 PTs and 43 DCs with a median experience of 15 years and 59% were females) registered 3500 patient visits. On average, the visits involved patients aged 51 years, and 51% were with females. The frequencies of common care elements across professions were information (42%-56% of visits between professions) and advice (56%-81%), while other common elements for GPs were pain medication (40%) and referrals to PTs (36%), for PTs, use of exercises (81%) and for DCs, use of manual therapy (96%). Substantial variation was observed within professions and distinct practice patterns, with different focuses of attention to information and advice versus exercise and manual therapy, were identified for PTs and DCs.

CONCLUSIONS

These data indicate substantial variation in the care elements provided by GPs, PTs and DCs to LBP patients. The compositions of care and practice patterns identified challenge the understanding of usual care as a uniform concept and professions as homogeneous groups. Strategic use of particular care elements in different parts of treatment courses is indicated. Longitudinal data and qualitative enquiry are needed to assess if or how care is tailored to individual patients.

Cepharanthine and Oral Lichen Planus Efficacy (COLE) study: protocol for a multicentre randomised controlled study assessing the efficacy and safety of cepharanthine with topical corticosteroids in oral lichen planus

INTRODUCTION

Oral lichen planus (OLP) is a chronic, inflammatory oral condition leading to a range of symptoms from mild discomfort to severe pain, affecting patients' quality of life. Standard therapy involves the use of topical corticosteroids, although some patients respond insufficiently or develop resistance to therapy. We aim to explore if adding cepharanthine, an herbal extract from Stephania cepharantha Hayata, can enhance the efficacy of corticosteroid therapy in symptomatic OLP.

METHODS AND ANALYSIS

This open-label, parallel-group, multi-centre, randomised controlled study will be conducted at three Japanese hospitals. It will compare safety and efficacy of integrated oral cepharanthine and corticosteroid therapy versus standard corticosteroid therapy. 50 symptomatic OLP patients will be randomised 1:1 to receive cepharanthine (30 mg/day) plus topical dexamethasone, or topical dexamethasone alone for 8 weeks. The primary outcome will be changed in pain intensity while drinking room-temperature water, measured on a visual analogue scale. The primary outcome is the change in pain intensity from baseline when drinking room-temperature water, evaluated using a visual analogue scale. Secondary outcomes are changes in the longest diameter of the target lesion from baseline to weeks 4 and 8, improvement and deterioration rates according to appearance and severity criteria at weeks 4 and 8, change in pain intensity when drinking room-temperature water from baseline to week 4, changes in pain intensity at rest from baseline to weeks 4 and 8, and the rates of adverse events.

ETHICS AND DISSEMINATION

This protocol was approved by the Certified Review Board of Nara Medical University (CRB5200002). Participants will provide informed consent. Results will be disseminated in peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

Japan Registry of Clinical Trials (jRCTs051220130).

Pain related to intravitreal injections for age-related macular degeneration: a qualitative study of the perspectives of patients and practitioners

OBJECTIVES

Ocular pain is a commonly reported finding in the intravitreal injection procedure, but post-injection experiences and patient adherence to treatment remain underexplored. We therefore aimed to identify key variations in the intravitreal injection procedure that may influence pain, and to gain insights into the post-injection experience and treatment adherence from the perspective of patients and practitioners.

DESIGN

Qualitative semistructured interview study using reflexive thematic analysis of transcripts.

SETTING

Hospital Eye Clinic in Wales, UK. Interviews were conducted between May and September 2019.

PARTICIPANTS

Purposive sample of patients aged ≥50 years with neovascular age-related macular degeneration and no other retinal pathology who had received at least six intravitreal injections, and practitioners including ophthalmologists, registered nurses and optometrists who performed intravitreal injections at the research site.

RESULTS

Data saturation was reached with 21 interviews: 14 patients and 7 practitioners. Three main themes were identified from the analysis: fear of losing eyesight and treatment anxiety influence patient adherence to treatment, variability in pain experience during treatment, and post-injection experience and impact on patient recovery. To reassure patients feeling apprehensive about the injections, practitioners promoted safety and trust, and used techniques to manage anxiety. Key variations that may influence pain identified were application of antiseptic or anaesthetic, injecting methods and communication. During injection, patients reported a dull-aching and sharp pain, contrary to practitioners' perspective of feeling a 'pressure'. Patients described prolonged soreness and irritation of up to 36 hours post-injection affecting their sleep and recovery.

CONCLUSION

Establishing rapport supported patients to recognise the necessity of ongoing treatment to prevent sight loss; however, inadequate pain management led to undesirable outcomes. Practitioners should use pain assessment tools during and immediately after injection and provide ongoing consistent information to help patients manage pain at home.

Predictive performance of the STarT Back tool for poor outcomes in patients with low back pain: protocol for a systematic review and meta-analysis

INTRODUCTION

Subgroups for Targeted Treatment Back Tool (SBT) is a brief multiple-construct risk prediction tool for patients with low back pain (LBP). Thus far, the predictive ability of this tool has been inconsistent. Therefore, we aim to conduct a literature review on the predictive ability of the SBT to determine the outcomes of patients with LBP. The results of this review should improve the ability of the SBT to predict poor outcomes in patients with LBP.

METHODS AND ANALYSIS

Databases including PubMed, EMBASE, Cochrane Central, Web of Science, Chinese National Knowledge Infrastructure Databases, Chinese Science and Technology Journal Database, and Wanfang will be searched for studies on SBT and LBP from their inception until 31 March 2023. Longitudinal studies investigating the association between SBT subgroups and LBP outcomes, including pain, disability and quality of life, will be included. The identified studies will be independently screened for eligibility by two reviewers. A standardised sheet will be used to extract data. The Newcastle-Ottawa Scale will be used to assess the methodological quality of the included studies. Heterogeneity will be evaluated by the χ2 test with Cochran's Q statistic and quantified by the I2 statistic. The results will be synthesised qualitatively and presented as pooled risk ratios or beta coefficients quantitatively. The results will also be presented using their 95% confidence limits. Publication bias will be assessed using the method proposed by Egger and by visual inspection of funnel plots.

ETHICS AND DISSEMINATION

This study is a secondary analysis of original studies that received ethics approval. Therefore, prior ethical approval is not required for this study. The findings will be submitted to relevant peer-reviewed journals for publication and presented at profession-specific conferences.

TRIAL REGISTRATION NUMBER

PROSPERO registration numberCRD42022309189.

Digital home monitoring for capturing daily fluctuation of symptoms; a longitudinal repeated measures study: Long Covid Multi-disciplinary Consortium to Optimise Treatments and Services across the NHS (a LOCOMOTION study)

INTRODUCTION

A substantial proportion of COVID-19 survivors continue to have symptoms more than 3 months after infection, especially of those who required medical intervention. Lasting symptoms are wide-ranging, and presentation varies between individuals and fluctuates within an individual. Improved understanding of undulation in symptoms and triggers may improve efficacy of healthcare providers and enable individuals to better self-manage their Long Covid. We present a protocol where we aim to develop and examine the feasibility and usability of digital home monitoring for capturing daily fluctuation of symptoms in individuals with Long Covid and provide data to facilitate a personalised approach to the classification and management of Long Covid symptoms.

METHODS AND ANALYSIS

This study is a longitudinal prospective cohort study of adults with Long Covid accessing 10 National Health Service (NHS) rehabilitation services in the UK. We aim to recruit 400 people from participating NHS sites. At referral to study, 6 weeks and 12 weeks, participants will complete demographic data (referral to study) and clinical outcome measures, including ecological momentary assessment (EMA) using personal mobile devices. EMA items are adapted from the COVID-19 Yorkshire Rehabilitation Scale items and include self-reported activities, symptoms and psychological factors. Passive activity data will be collected through wrist-worn sensors. We will use latent class growth models to identify trajectories of experience, potential phenotypes defined by co-occurrence of symptoms and inter-relationships between stressors, symptoms and participation in daily activities. We anticipate that n=300 participants provide 80% power to detect a 20% improvement in fatigue over 12 weeks in one class of patients relative to another.

ETHICS AND DISSEMINATION

The study was approved by the Yorkshire & The Humber-Bradford Leeds Research Ethics Committee (ref: 21/YH/0276). Findings will be disseminated in peer-reviewed publications and presented at conferences.

TRIAL REGISTRATION NUMBER

ISRCTN15022307.

Identifying physical and psychological risk factors for musculoskeletal pain in student musicians to tailor the curriculum: a cross-sectional study protocol

INTRODUCTION

Insufficient identification and understanding of risk factors make musicians engaging in professional practice particularly vulnerable to musculoskeletal pain. To support positive music learning and good mental, physical, and social health, student musicians need health support tailored to their needs and their instrumental practice. However, these preventive actions must be based on sound scientific approaches that reliably identify the most relevant risk factors. MuSa is a cross-sectional study examining contextual and internal risk variables associated with playing-related musculoskeletal disorders in student musicians.

METHOD AND ANALYSIS

The design is a monocentric cross-sectional study involving student musicians in Bachelor's 1, 2, 3 and Master's 1, 2. Free-form questions will identify students' lifestyle characteristics and work habits, and validated questionnaires will evaluate the interaction between pain due to music practice and psychological and physical risk factors. All data will first be analysed descriptively. Psychological network analysis will be used to explore the overall correlational structure of the dataset. A subgroup comparative analysis will be then applied according to the instrumental subcategories and work postures, including singers.

ETHICS AND DISSEMINATION

The full protocol was approved by the Swiss Ethics Committee 'Commission Cantonale d'Ethique de la Recherche sur l'être humain de Genève' (CCER, no. 2022-02206) on 13 February 2023. Outcomes will be disseminated through publication in peer-reviewed journals and presentations at conferences.

Sex and gender differences in healthcare utilisation trajectories: a cohort study among Quebec workers living with chronic pain

OBJECTIVES

Chronic pain (CP) is a poorly recognised and frequently inadequately treated condition affecting one in five adults. Reflecting on sociodemographic disparities as barriers to CP care in Canada was recently established as a federal priority. The objective of this study was to assess sex and gender differences in healthcare utilisation trajectories among workers living with CP.

DESIGN

Retrospective cohort study.

PARTICIPANTS

This study was conducted using the TorSaDE Cohort which links the 2007-2016 Canadian Community Health Surveys and Quebec administrative databases (longitudinal claims). Among 2955 workers living with CP, the annual number of healthcare contacts was computed during the 3 years after survey completion.

OUTCOME

Group-based trajectory modelling was used to identify subgroups of individuals with similar patterns of healthcare utilisation over time (healthcare utilisation trajectories).

RESULTS

Across the study population, three distinct 3-year healthcare utilisation trajectories were found: (1) low healthcare users (59.9%), (2) moderate healthcare users (33.6%) and (3) heavy healthcare users (6.4%). Sex and gender differences were found in the number of distinct trajectories and the stability of the number of healthcare contacts over time. Multivariable analysis revealed that independent of other sociodemographic characteristics and severity of health condition, sex-but not gender-was associated with the heavy healthcare utilisation longitudinal trajectory (with females showing a greater likelihood; OR 2.6, 95% CI 1.6 to 4.1).

CONCLUSIONS

Our results underline the importance of assessing sex-based disparities in help-seeking behaviours, access to healthcare and resource utilisation among persons living with CP.

Understanding the chronic pain journey and coping strategies that patients use to manage their chronic pain: a qualitative, patient-led, Canadian study

OBJECTIVE

To gain an insight into coping strategies that people living with chronic pain use to self-manage their pain.

DESIGN

This qualitative Patient-oriented Research study used the Patient and Community Engagement Research approach. It was conducted by people with chronic pain lived experience, ensuring that patient perspective and needs were considered and addressed throughout the research cycle. Purposeful sampling was used for recruiting individuals living with chronic pain. A focus group and one-on-one semi-structured interviews were conducted via videoconference. The data were analysed iteratively using inductive thematic analysis and narrative story analysis.

SETTING

Calgary, Alberta, Canada.

PARTICIPANTS

Eleven adult participants, between the ages of 18 and 65, who self-identified as living with chronic pain for greater than 2 years.

RESULTS

Three main themes emerged from the data: (1) the elements of chronic pain, (2) the chronic pain journey to acceptance and (3) daily coping strategies for chronic pain. Participants thought it was important to discuss these three themes because the daily coping strategies that they employed at any given time (theme 3) depended on the factors discussed in themes 1 and 2. Overlaying all of this is also a grieving process that people living with chronic pain may have to go through more than once. Participants also identified recommendations for healthcare professionals to support people living with chronic pain.

CONCLUSIONS

Dealing with chronic pain affects all aspects of a person's life and involves a grieving process. When treating patients with chronic pain, it is important for healthcare professionals to understand the journey that people living with chronic pain go through, not just coping strategies. Diagnosis is critical for a patient's acceptance and in helping them find their new normal where they can employ daily coping strategies to manage their pain.

Substituting a randomised placebo control group with a historical placebo control in an endometriosis pain trial: a case study re-evaluating trial data using historical control data from another trial

OBJECTIVE

The substitution of an in-study control population with a historical control (HC) population is considered a viable option for reducing the necessary recruitment of control patients. However, it is necessary to evaluate whether this method is applicable to studies on indications targeting endometriosis-associated pelvic pain (EAPP). This study aims to evaluate the potential bias in the results of an EAPP study with an HC arm.

METHODS

For this case study, we re-evaluated data from a randomised, placebo-controlled trial using dienogest daily to treat EAPP with an HC arm based on data from a second randomised, placebo-controlled trial in the same indication. Propensity Score (PS) matching was used to match between the treatment and HC arm on all baseline variables. To evaluate the effect of matching on the introduced bias, we evaluated efficacy parameters with the full treatment and control group, as well as the matched group.

RESULTS

The difference between means (placebo minus treatment) in change in pain, as measured on the Visual Analogue Scale from baseline to end of treatment, deviates in the comparison treatment/pool of HC (7.15 (0.22 to 14.08)) from the overall in-study group (reference: 11.89 (6.06 to 17.73)). After PS matching on the baseline variables, the difference between means (11.79 (4.09 to 19.5)) is close to the reference.

CONCLUSIONS

Using HC with PS matching has proven to be useful in the setting of treating EAPP, while emphasis must be given to the selection mechanism and the underlying assumptions. This case study has shown that even for studies which are very similar in design, heterogeneity and between-study variations are present. With the use of an HC arm, it was possible to reproduce similar results than in the original study, while the PS matching improved the comparability considerably. For the main endpoint, PS matching could reproduce the original study results.

TRIAL REGISTRATION NUMBER

NCT00225199, NCT00185341.

Proof of concept of prehabilitation: a combination of education and behavioural change, to promote physical activity in people with fibromyalgia

OBJECTIVES

To establish proof of concept of a prehabilitation intervention, a combination of education and behavioural change, preceding a physical activity programme in people with fibromyalgia (FM).

SETTINGS

Open-label, feasibility clinical trial.

PARTICIPANTS

Eleven people with FM (10 women).

INTERVENTIONS

The prehabilitation intervention consisted of 4 weeks, 1 weekly session (~1 to 1.5 hours), aimed to increase self-efficacy and understand why and how to engage in a gentle and self-paced physical activity programme (6 weeks of walking with telephone support).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was the acceptability and credibility of the intervention by means of the Credibility/Expectancy Questionnaire. Secondary outcomes comprised scales to measure FM severity, specific symptoms and sedentary behaviour. An exit interview was conducted to identify the strengths and weaknesses and barriers to the intervention.

RESULTS

One participant dropped out due to finding the walking programme excessively stressful. Participants expected the intervention would improve their symptoms by 22%-38% but resulted in 5%-26% improvements. Participants would be confident in recommending this intervention to a friend who experiences similar problems. The interviews suggested that the fluctuation of symptoms should be considered as an outcome and that the prehabilitation intervention should accomodate these fluctuation. Additional suggestions were to incorporate initial interviews (patient-centred approach), to tailor the programmes to individuals' priorities and to offer a variety of physical activity programmes to improve motivation.

CONCLUSIONS

This feasibility study demonstrated that our novel approach is acceptable to people with FM. Future interventions should pay attention to flexibility, symptoms fluctuation and patients support.

TRIAL REGISTRATION NUMBER

NCT03764397.

Health economic impact of moderate-to-severe chronic pain associated with osteoarthritis in England: a retrospective analysis of linked primary and secondary care data

OBJECTIVE

Despite the prevalence of osteoarthritis (OA) in England, few studies have examined the health economic impact of chronic pain associated with OA. The aim of this study was to compare outcomes in patients with moderate-to-severe chronic pain associated with OA and matched controls without known OA.

DESIGN

Retrospective, longitudinal, observational cohort study.

SETTING

Electronic records extracted from the Clinical Practice Research Datalink GOLD primary care database linked to Hospital Episode Statistics (HES) data set.

PARTICIPANTS

Patients (cases; n=5931) ≥18 years and with existing diagnosis of OA and moderate-to-severe pain associated with their OA, and controls matched on age, sex, comorbidity burden, general practitioner (GP) practice and availability of HES data.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total healthcare resource use (HCRU) and direct healthcare costs during 0-6, 0-12, 0-24 and 0-36 months of follow-up. Secondary outcomes measures included pharmacological management and time to total joint replacement.

RESULTS

Patients with moderate-to-severe chronic pain associated with OA used significantly more healthcare services versus matched controls, reflected by higher HCRU and significantly higher direct costs. During the first 12 months' follow-up, cases had significantly more GP consultations, outpatient attendances, emergency department visits and inpatient stays than matched controls (all p<0.0001). Total mean costs incurred by cases during 0-12 months' follow-up were five times higher in cases versus controls (mean (SD): £4199 (£3966) vs £781 (£2073), respectively). Extensive cycling through pharmacological therapies was observed; among cases, 2040 (34.4%), 1340 (22.6%), 841 (14.2%), 459 (7.7%) and 706 (11.9%) received 1-5, 6-10, 11-15, 16-20 and >20 lines of therapy, respectively.

CONCLUSIONS

This wide-ranging, longitudinal, observational study of real-world primary and secondary care data demonstrates the impact of moderate-to-severe chronic pain associated with OA in patients compared with matched controls. Further studies are required to fully quantify the health economic burden of moderate-to-severe pain associated with OA.

Is the equimolar mixture of oxygen and nitrous oxide (EMONO) associated with audiovisuals effective in reducing pain and side effects during peripheral venous access placement in children? Protocol for a single-centre randomised controlled trial from Italy

INTRODUCTION

Nurses frequently place a peripheral venous catheter during children's hospitalisation. Many studies suggest treatment of venipuncture-related pain. The administration of an equimolar mixture of oxygen and nitrous oxide (EMONO) is employed for pain control; however, no studies have analysed the association between EMONO and audiovisuals.The purpose of the study is to evaluate the effect of EMONO administration when combined with audiovisuals (EMONO+Audiovisual) versus EMONO alone on perceived pain, side effects and level of cooperation during peripheral venous access placement in children aged 2-5 years.

METHODS AND ANALYSIS

The first 120 eligible children admitted to the paediatric ward of the Lodi Hospital and presenting the indication for peripheral venous access will be enrolled. Sixty children will be randomly assigned to the experimental group (EMONO+Audiovisual) and 60 to the control group (EMONO alone).The Face, Legs, Activity, Cry, Consolability scale will be used to assess pain in the children aged 2-years old; pain in the children aged 3-5 years will be assessed using the Wong-Baker scale. The cooperation throughout the procedure will be measured using the Groningen Distress Rating Scale.

ETHICS AND DISSEMINATION

The Milan Area 1 Ethics Committee approved the study protocol (Experiment Registry No. 2020/ST/295). The trial results will be presented at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05435118.

Patients' experiences with the application of medical adhesives to the skin: a qualitative systematic review protocol

INTRODUCTION

Medical adhesives are adhesives used in medical devices to establish and maintain contact with the body over a period of time (usually by application to the skin) and are widely used in most care settings. Application of medical adhesives to the skin can lead to skin stripping, mild or severe allergic reactions and skin irritation that may manifest as redness, itching or rash. Adhesive-related skin injury can lead to infection, delayed wound healing and an increased risk of scarring. These injuries can cause severe discomfort and pain, and can affect the patient's quality of life. A systematic review summarising patient's experiences on this topic will contribute to informing adhesive producers and policy makers, and guiding further development and improvement of available technologies.

METHODS AND ANALYSIS

This systematic review protocol is based on the principles of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline. A systematic search will be conducted in CINAHL, EMBASE, MEDLINE and PsycINFO. In addition, manual searches will be performed, reviewing the reference lists of relevant reviews and articles included for quality assessment. Qualitative studies using various methods will be considered for inclusion. Screening of title, abstract and full text will be done by two reviewers. The methodological quality of studies under consideration will be critically assessed by two reviewers using the Joanna Briggs Institute Critical Appraisal Tool for Qualitative Research. Data extraction will be performed independently by two reviewers using a predefined data extraction form. Meta-aggregation will be used to summarise the evidence.

ETHICS AND DISSEMINATION

No ethical approval or consent is required because no participants will be recruited. This systematic review protocol is published in an open access journal to increase transparency of the research methods used. Results will be disseminated at national and international conferences.

Photobiomodulation and glass ionomer sealant as complementary treatment for hypersensitivity in molar incisor hypomineralisation in children: protocol for a blinded randomised clinical trial

INTRODUCTION

Photobiomodulation has been widely used as a complementary treatment for dentin hypersensitivity, with reports of clinical success. However, the literature offers only one study, in which photobiomodulation was used for the treatment of sensitivity in molars with molar incisor hypomineralisation (MIH). The aim of the proposed study is to determine whether photobiomodulation enhances the results of treatment with glass ionomer sealant on molars with MIH that present sensitivity.

METHODS AND ANALYSIS

The study involves 50 patients from 6 to 12 years of age that will be randomly allocated in two groups. Group 1 (control group) (n=25): toothpaste with a concentration of fluoride ≤1000 ppm two times a day, glass ionomer sealant and sham low-level laser (LLL) and group 2 (n=25): toothpaste with a concentration of fluoride ≤1000 ppm two times a day, glass ionomer sealant and active LLL. The evaluations will involve MIH record, Simplified Oral Hygiene Index (OHI), Schiff Cold Air Sensitivity Scale (SCASS) and visual analogue scale (VAS) before the procedure. Immediately after the procedure, the hypersensitivity index (SCASS/VAS) will be registered. Records of OHI and SCASS/VAS will be registered after 48 hours as well as 1 month after the procedure. The persistence of the sealant will also be registered. It is expected that by the second consultation, a decrease in sensitivity will be observed due to the treatments received in the two groups.

ETHICS AND DISSEMINATION

This protocol has been approved by the local medical ethical committee (certificate: CEUCU 220516). The findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05370417.