Understanding the Experiences of Clinicians Accessing Electronic Databases to Search for Evidence on Pain Management Using a Mixed Methods Approach.

The act of searching and retrieving evidence falls under the second step of the EBP process-tracking down the best evidence. The purpose of this study is to understand the competencies of clinicians accessing electronic databases to search for evidence on pain management using a mixed methods approach. Thirty-seven healthcare professionals (14 occupational therapists, 13 physical therapists, 8 nurses, and 2 psychologists) who are actively involved in pain management were included. This study involved two parts (a qualitative and a quantitative part) that ran in parallel. Participants were interviewed using a semi-structured interview guide (qualitative data); data were transcribed verbatim. During the interview, participants were evaluated in comparison to a set of pre-determined practice competencies using a chart-stimulated recall (CSR) technique (quantitative data). CSR was scored on a 7-point Likert scale. Coding was completed by two raters; themes across each of the competencies were integrated by three raters. Seven themes evolved out of the qualitative responses to these competencies: formulating a research question, sources of evidence accessed, search strategy, refining the yield, barriers and facilitators, clinical decision making, and knowledge and awareness about appraising the quality of evidence. The qualitative results informed an understanding of the strengths and weaknesses in the competencies evaluated. In conclusion, using a mixed methods approach, we found that clinicians were performing well with their basic literature review skills, but when it came to advanced skills like using Boolean operators, critical appraisal and finding levels of evidence they seem to require more training.

Effects of childhood trauma on pain-related distress in adults.

BACKGROUND: Much of the work in post-musculoskeletal (MSK) trauma and distress has been conducted through frameworks that start from the injury and go forward to better understand the trajectories and predictors of recovery. However, stress-diatheses models suggest that reactions to trauma are shaped by pre-existing experiences of the person more than the parameters of the event itself. In this study, we explore the effects of adverse childhood experiences (ACEs) on traumatic threat appraisal, distress and pain-related functional interference in adulthood. METHODS: Adult participants with acute, non-catastrophic musculoskeletal trauma completed a battery of questionnaires that included the Adverse Childhood Experiences Questionnaire (ACEQ), the Brief Illness Perceptions Questionnaire (BIPQ), the Traumatic Injuries Distress Scale (TIDS) and the Brief Pain Inventory (BPI). An a priori model was evaluated through path analysis to determine the variance in BPI Interference scores explained through direct or indirect pathways between these variables (ACEQ->BIPQ, BIPQ->TIDS, TIDS->BPI). The analysis was repeated for the sample when disaggregated by sex. RESULTS: In n = 114, the base model was saturated. After removing non-significant pathways, the ACEQ->BIPQ->TIDS->BPI paths were significant and in the expected direction, explaining 57.1% of variance in acute BPI Interference score. When disaggregated by sex, the effect of ACEs on threat appraisal was only significant in men and not women, although this analysis was exploratory. CONCLUSIONS: Acute pain-related interference could be predicted by post-traumatic distress and threat appraisal. Threat appraisal could be further predicted through ACEs, more childhood adversities were associated with more threatening appraisal of trauma in adulthood. The disaggregated finding that the effects of childhood adversities were only significant in males requires further exploration. SIGNIFICANCE: This study explores the potential pathways of the stress-diathesis model while focusing on adverse childhood experiences as a novel contribution to the field of acute post-trauma pain. The findings may inform future research design and interpretation of acute-to-chronic pain risk stratification tools.

The yield and usefulness of PAIN+ and PubMed databases for accessing research evidence on pain management: a randomized crossover trial.

INTRODUCTION: PAIN+ and PubMed are two electronic databases with two different mechanisms of evidence retrieval. PubMed is used to "Pull" evidence where clinicians can enter search terms to find answers while PAIN+ is a newly developed evidence repository where along with "Pull" service there is a "Push" service that alerts users about new research and the associated quality ratings, based on the individual preferences for content and altering criteria. PURPOSE: The primary purpose of the study was to compare yield and usefulness of PubMed and PAIN+ in retrieving evidence to address clinical research questions on pain management. The secondary purpose of the study was to identify what search terms and methods were used by clinicians to target pain research. STUDY DESIGN: Two-phase double blinded randomized crossover trial. METHODS: Clinicians (n = 76) who were exposed to PAIN+ for at least 1 year took part in this study. Participants were required to search for evidence 2 clinical question scenarios independently. The first clinical question was provided to all participants and thus, was multi-disciplinary. Participants were randomly assigned to search for evidence on their clinical question using either PAIN+ or PubMed through the electronic interface. Upon completion of the search with one search engine, they were crossed over to the other search engine. A similar process was done for a second scenario that was discipline-specific. The yield was calculated using number of retrieved articles presented to participants and usefulness was evaluated using a series of Likert scale questions embedded in the testing. RESULTS: Multidisciplinary scenario: Overall, the participants had an overall one-page yield of 715 articles for PAIN+ and 1135 articles for PubMed. The topmost article retrieved by PAIN+ was rated as more useful (p = 0.001). While, the topmost article retrieved by PubMed was rated as consistent with current clinical practice (p = 0.02). PubMed (48%) was preferred over PAIN+ (39%) to perform multidisciplinary search (p = 0.02). Discipline specific scenario: The participants had an overall one-page yield of 1046 articles for PAIN+ and 1398 articles for PubMed. The topmost article retrieved by PAIN+ was rated as more useful (p = 0.001) and consistent with current clinical practice (p = 0.02) than the articles retrieved by PubMed. PAIN+ (52%) was preferred over PubMed (29%) to perform discipline specific search. CONCLUSION: Clinicians from different disciplines find both PAIN+ and PubMed useful for retrieving research studies to address clinical questions about pain management. Greater preferences and perceived usefulness of the top 3 retrieved papers was observed for PAIN+, but other dimensions of usefulness did not consistently favor either search engine. TRIAL REGISTRATION: Registered with ClinicalTrials.gov Identifier: NCT01348802 , Date: May 5, 2011.

Integration of evidence across human and model organism studies: A meeting report.

The National Institute on Drug Abuse and Joint Institute for Biological Sciences at the Oak Ridge National Laboratory hosted a meeting attended by a diverse group of scientists with expertise in substance use disorders (SUDs), computational biology, and FAIR (Findability, Accessibility, Interoperability, and Reusability) data sharing. The meeting's objective was to discuss and evaluate better strategies to integrate genetic, epigenetic, and 'omics data across human and model organisms to achieve deeper mechanistic insight into SUDs. Specific topics were to (a) evaluate the current state of substance use genetics and genomics research and fundamental gaps, (b) identify opportunities and challenges of integration and sharing across species and data types, (c) identify current tools and resources for integration of genetic, epigenetic, and phenotypic data, (d) discuss steps and impediment related to data integration, and (e) outline future steps to support more effective collaboration-particularly between animal model research communities and human genetics and clinical research teams. This review summarizes key facets of this catalytic discussion with a focus on new opportunities and gaps in resources and knowledge on SUDs.

Association Between Knee Load and Pain: Within-Patient, Between-Knees, Case-Control Study in Patients With Knee Osteoarthritis.

OBJECTIVE: The association between knee loading and pain in patients with knee osteoarthritis is reported to be low and of questionable importance, but may be confounded by several factors that differ between patients. We aimed to elucidate the association between dynamic knee load and pain by minimizing confounding using a study design that was within the same patient, with knees discordant for pain. METHODS: A total of 265 patients with knees discordant for pain (530 knees) rated the pain in each knee before and after walking for 6 minutes, and then underwent 3-dimensional gait analysis. RESULTS: The peak knee adduction moment and knee adduction impulse (proxies for medial knee loading) were associated with increased pain (odds ratio [OR] 2.43 [95% confidence interval (95% CI) 1.77-3.33] and OR 6.62 [95% CI 3.46-12.7], respectively) and remained significant after controlling for radiographic disease severity. When split into quartiles, ORs indicated knees in the highest loading quartile had greater odds of experiencing increased pain with walking (OR 4.7 95% CI 2.3-9.5] for peak adduction moment; OR 9.0 [95% CI 4.0-20.1] for adduction impulse) compared to knees in the lowest loading quartile. CONCLUSION: When between-patient confounding is minimized, there is a strong association between medial knee load and increased knee pain during walking.

What Factors Contribute to Falls-Related Distal Radius Fracture?

Objective: This mixed methods study analyzed the factors that led to a fall in a cohort of patients with distal radius fracture (DRF). Methods: A sample of 1,453 patients (430 men; 1,023 women; age range: 18-89 years) supplemented by new interview data from 29 patients (19 women) were examined. Chi-square and descriptive analysis of quantitative data and descriptive thematic analysis of qualitative data were compared to determine data convergence and divergence. Results: A higher number of DRF were observed in the 45- to 64-year-old group (44%), employed people (48%), in winter months (41%), and in low-energy fractures (75%). Themes emerged from qualitative data on the cause of the fracture, including environmental factors, behavioral factors, physical factors, and sports activities. Conclusion: Reasons for DRF are multifactorial. Preventive strategies with an emphasis on environmental and behavioral factor modifications are likely to decrease the number of DRF.

Attitudes, knowledge and behaviors related to evidence-based practice in health professionals involved in pain management.

BACKGROUND: Healthcare professionals involved in pain management come from different disciplines, which may have different perspectives and training about evidence-based practice (EBP). A common concern for health professionals is pain management. Understanding how different professions involved in pain management view EBP forms the ideal context to study professional differences in EPP, and how this might influence pain management. PURPOSE: The purpose of this study was to compare different professions with respect to knowledge, attitudes and self-reported behavior toward EBP. STUDY DESIGN: Cross-sectional study. METHODS: Physicians, nurses, occupational therapists, physical therapists and psychologists who were involved in pain management (n = 675) completed an online survey on a single occasion. The survey included demographic questions and the EBP-knowledge, attitude, behavior questionnaire (EBP-KABQ). This is a 27-item questionnaire that has been validated for use with different health professionals, and measures four constructs related to EBP (knowledge, attitude, behavior and outcome/decision). Differences between professionals were identified using a one-way between groups analysis of variance, with post-hoc testing (statistical significance was set at P value less than 0.05; clinical significance set at a mean difference of 10%). RESULTS: The score on three of the four subscales of the KABQ were statistically different across professions. In general, knowledge scores were high for all professions (83-87%). Nurses demonstrated statistically higher levels of EBP knowledge (87%) when compared with other groups (F = 4.79, P = 0.001), but the differences were not deemed clinically relevant. Behavior was the lowest subscale and the most variable across professions (37-56%). Physicians had statistically significant (F = 25.69; P = 0.001), and clinically relevant, higher behavior subscale scores (56%) when compared with other professional groups. Physicians (73%) also had higher outcome/decision subscale scores (F = 6.50; P = 0.001), but this was only marginally different from other professions (65-73%). The attitude subscale scores were low and were not different across professions (range 57-59%; F = 1.65, P = 0.16; NS). CONCLUSION: The current study indicates that physicians and allied health professionals have similar EBP attitudes and knowledge. All professional groups seem to have suboptimal implementation of EBP. The nature of medical decision-making, its evidentiary pool, or longer experience with EBP may contribute to greater implementation amongst physicians.

Confirmatory Factor and Rasch Analyses Support a Revised 14-Item Version of the Organizational, Policies, and Practices (OPP) Scale.

Background The long version of the organizational, policies and practices (OPP) had a high burden and short versions were developed to solve this drawback. The 11-item version showed promise, but the ergonomic subscale was deficient. The OPP-14 was developed by adding three additional items to the ergonomics subscale. The aim of this study is to evaluate the factor structure using confirmatory factor and Rasch analyses in healthy firefighters. Methods A sample of 261 firefighters (Mean age 42 years, 95 % male) were sampled. A confirmatory factor and Rasch analyses were used to assess the internal consistency, factor structure and other psychometric characteristics of revised OPP-14. Results The OPP-14 demonstrates sound factor structure and internal consistency in firefighters. Confirmatory factor analysis confirmed the consistency of the original 4-domain structure (CFI = 0.97, TLI = 0.96, and RMSEA = 0.053). The 5 items showing misfit initially with disordered thresholds were rescored. The four subscales satisfied Rasch expectations with well target and acceptable reliability. Conclusions The OPP-14 scale shows a promising factor structure in this sample and remediated deficits found in OPP-11. This version may be preferable for musculoskeletal concerns or work applications where ergonomic indicators are relevant.

Evaluating the reliability of a novel neck-strength assessment protocol for healthy adults using self-generated resistance with a hand-held dynamometer.

PURPOSE: To evaluate the intra- and inter-session test-retest agreement of a novel neck-strength assessment protocol using a hand-held dynamometer. BACKGROUND: A literature review found a lack of neck-strength assessment protocols that are both portable and reliable. Hand-held dynamometry is a portable and inexpensive method of assessing muscle strength, but it is not commonly used for neck-strength assessment. METHODS: A hand-held dynamometer was used to evaluate neck strength in 30 healthy participants. The device measured maximum force in cervical flexion, extension, side flexion, side flexion with rotation, and pure rotation, using the ipsilateral hand to apply isometric resistance over 3 seconds. Three measurements were taken over 6-8 days. RESULTS: Test-retest intra-class correlation coefficients (ICCs) showed high reliability, ranging from 0.94 to 0.97 for all tested directions from Trial 1 to Trial 2 (intra-session reliability, ICC [2,1], absolute). ICC values demonstrated good to high inter-session reliability, ranging from 0.87 to 0.95 for all tested directions from Trial 1 to Trial 3 (ICC [2,1], absolute). CONCLUSION: The results suggest that the five test positions of the neck and upper-quadrant strength assessment protocol can be performed using hand-held dynamometry with good to high reliability.

Objectif : Évaluer la convergence test-retest intra et intersessionnelle d'un nouveau protocole d'évaluation de la force du cou au moyen d'un dynamomètre portatif. Contexte: Une recension des écrits a révélé un manque de protocoles d'évaluation de la force du cou à la fois portables et fiables. La dynamométrie manuelle est une méthode portable et peu coûteuse d'évaluation de la force musculaire, mais elle n'est pas utilisée couramment pour évaluer la force du cou. Méthodes : On a utilisé un dynamomètre portatif pour évaluer la force du cou chez 30 participants en bonne santé. On a mesuré la force maximale en flexion cervicale, extension, flexion latérale, flexion latérale avec rotation et rotation pure en utilisant la main ipsilatérale pour appliquer une résistance isométrique pendant 3 secondes. On a pris trois mesures en 6 à 8 jours. Résultats : Les coefficients de corrélation intraclasse (CCI) de test-retest ont révélé une grande fiabilité variant de 0,94 à 0,97 dans le cas de toutes les directions vérifiées de l'essai 1 à l'essai 2 (fiabilité intrasessionnelle) [CCI (2,1), absolu]. Les valeurs CCI ont démontré une fiabilité intersessionnelle variant de bonne à élevée, variant de 0,87 à 0,95 dans le cas de toutes les directions mises à l'épreuve de l'essai 1 à l'essai 3 [CCI (2,1), absolu]. Conclusion : Les résultats indiquent qu'il est possible d'appliquer le protocole d'évaluation de la force du cou et du quadrant supérieur par les cinq positions d'essai en utilisant la dynamométrie manuelle, et qu'il produit une fiabilité variant de bonne à élevée.

The construct validity and responsiveness of sensory tests in patients with carpal tunnel syndrome.

BACKGROUND AND PURPOSE: Sensory evaluation is fundamental to evaluation of patients with Carpal Tunnel Syndrome (CTS). The purpose of this study was to determine the construct validity and responsiveness for sensory threshold tests in patients with CTS. METHODS: Sixty-three patients diagnosed with CTS were evaluated prior to orthotic intervention and again at follow up at 6 and 12 weeks. Sensory tests included touch threshold PSSD (Pressure Specified Sensory Device) and vibration threshold (Vibrometer). Construct validity was assessed by comparing sensory tests to hand function, and dexterity testing using Spearman rho (rs). Patients were classified as either responders or non-responders to orthotic intervention based on the change score of the Symptom Severity Scale (SSS) of 0.5. Responsiveness of the sensory tools was measured using ROC (receiver operating characteristic) curves, SRM (Standardized Response Mean), and ES (Effect Sizes). RESULTS: The PSSD had low to moderate correlations (rs ≤ 0.32) while Vibrometer scores had moderate correlations (rs = 0.36 - 0.41) with dexterity scores. The Clinically Important Difference (CID) for the PSSD was estimated at 0.15 g/mm(2) but was not discriminative. The Vibrometer demonstrated moderate responsiveness, with a SRM = 0.61 and an ES = 0.46 among responders. The PSSD had a SRM = 0.09 and an ES = 0.08 and showed low responsiveness for patients with a clinically important improvement in symptoms. CONCLUSION: Measurement properties suggest that the Vibrometer was preferable to the PSSD because it was more correlated to hand function, and was more responsive. Clinicians may choose use the Vibrometer opposed to the PSSD for determining important change in sensation after orthotic intervention.

An ICON Overview on Physical Modalities for Neck Pain and Associated Disorders.

INTRODUCTION: Neck pain is common, can be disabling and is costly to society. Physical modalities are often included in neck rehabilitation programs. Interventions may include thermal, electrotherapy, ultrasound, mechanical traction, laser and acupuncture. Definitive knowledge regarding optimal modalities and dosage for neck pain management is limited. PURPOSE: To systematically review existing literature to establish the evidence-base for recommendations on physical modalities for acute to chronic neck pain. METHODS: A comprehensive computerized and manual search strategy from January 2000 to July 2012, systematic review methodological quality assessment using AMSTAR, qualitative assessment using a GRADE approach and recommendation presentation was included. Systematic or meta-analyses of studies evaluating physical modalities were eligible. Independent assessment by at least two review team members was conducted. Data extraction was performed by one reviewer and checked by a second. Disagreements were resolved by consensus. RESULTS: Of 103 reviews eligible, 20 were included and 83 were excluded. Short term pain relief - Moderate evidence of benefit: acupuncture, intermittent traction and laser were shown to be better than placebo for chronic neck pain. Moderate evidence of no benefit: pulsed ultrasound, infrared light or continuous traction was no better than placebo for acute whiplash associated disorder, chronic myofascial neck pain or subacute to chronic neck pain. There was no added benefit when hot packs were combined with mobilization, manipulation or electrical muscle stimulation for chronic neck pain, function or patient satisfaction at six month follow-up. CONCLUSIONS: The current state of the evidence favours acupuncture, laser and intermittent traction for chronic neck pain. Some electrotherapies show little benefit for chronic neck pain. Consistent dosage, improved design and long term follow-up continue to be the recommendations for future research.

Pharmacological Interventions Including Medical Injections for Neck Pain: An Overview as Part of the ICON Project.

OBJECTIVES: To conduct an overview (review-of-reviews) on pharmacological interventions for neck pain. SEARCH STRATEGY: Computerized databases and grey literature were searched from 2006 to 2012. SELECTION CRITERIA: Systematic reviews of randomized controlled trials (RCT) in adults with acute to chronic neck pain reporting effects of pharmacological interventions including injections on pain, function/disability, global perceived effect, quality of life and patient satisfaction. DATA COLLECTION & ANALYSIS: Two independent authors selected articles, assessed risk of bias and extracted data The GRADE tool was used to evaluate the body of evidence and an external panel provided critical review. MAIN RESULTS: We found 26 reviews reporting on 47 RCTs. Most pharmacological interventions had low to very low quality methodologic evidence with three exceptions. For chronic neck pain, there was evidence of: a small immediate benefit for eperison hydrochloride (moderate GRADE, 1 trial, 157 participants);no short-term pain relieving benefit for botulinum toxin-A compared to saline (strong GRADE; 5 trial meta-analysis, 258 participants) nor for subacute/chronic whiplash (moderate GRADE; 4 trial meta-analysis, 183 participants) including reduced pain, disability or global perceived effect; andno long-term benefit for medial branch block of facet joints with steroids (moderate GRADE; 1 trial, 120 participants) over placebo to reduce pain or disability; REVIEWERS' CONCLUSIONS: While in general there is a lack of evidence for most pharmacological interventions, current evidence is against botulinum toxin-A for chronic neck pain or subacute/chronic whiplash; against medial branch block with steroids for chronic facet joint pain; but in favour of the muscle relaxant eperison hydrochloride for chronic neck pain.

Can we identify people at risk of non-recovery after acute occupational low back pain? Results of a review and higher-order analysis.

PURPOSE: To identify prognostic factors in the literature that may predict a poor recovery from acute occupational low back pain (LBP). METHODS: Four international databases (Medline, CINAHL, EMBASE, and PsycINFO) were reviewed, searching all articles indexed up to November 2007 with the term low back pain combined with the terms prognostic, prospective, or cohort. Following application of inclusion criteria, 10 articles were found to be appropriate for data extraction. Each article was critically appraised by two independent reviewers. Statistical pooling was performed on any factor evaluated in at least three independent cohorts. RESULTS: Seven cohorts were identified, with a total sample size of 2,484 subjects. Only three factors were followed in at least three cohorts and were therefore suitable for statistical pooling: female gender (OR=1.28, 95% CI: 1.03-1.58); pain radiation (OR=1.37, 95% CI: 0.79-2.39); and previous history of back pain (OR=0.91, 95% CI: 0.52-1.60). There was significant heterogeneity within the female gender factor; compensation of subjects for study participation appeared to moderate its effect. CONCLUSION: After statistical pooling, only female gender achieved statistical significance as a prognostic factor for prolonged recovery. Further research is necessary to determine prognostic factors for non-recovery in acute LBP.