Pain-related fear in adolescents with chronic musculoskeletal pain: process evaluation of an interdisciplinary graded exposure program.

BACKGROUND: For studying the effectiveness of treatment, it is important to check whether a new treatment is performed as originally described in the study-protocol. OBJECTIVES: To evaluate whether an interdisciplinary graded exposure program, for adolescents with chronic musculoskeletal pain reporting pain-related fear, was performed according to protocol, and whether it is feasible to implement the program in rehabilitation care. METHODS: A process evaluation where quantitative and qualitative data on participant characteristics (adolescents, parents and therapists), attendance and participants' opinion on the program were collected, by means of registration forms, questionnaires and group interviews. To evaluate treatment fidelity, audio and video recordings of program sessions were analyzed. RESULTS: Thirty adolescents were offered the program, of which 23 started the program. Adolescents attended on average 90% of the sessions. At least one parent per adolescent participated in the program. Analysis of 20 randomly selected recordings of treatment sessions revealed that treatment fidelity was high, since 81% of essential treatment elements were offered to the adolescents. The program was considered client-centered by adolescents and family-centered by parents. Treatment teams wished to continue offering the program in their center. CONCLUSION: The interdisciplinary graded exposure program was performed largely according to protocol, and therapists, adolescents and their parents had a favorable opinion on the program. Implementation of the program in rehabilitation care is considered feasible. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT02181725 (7 February 2014).

Early treatment of trans-tibial amputees: retrospective analysis of early fitting and elastic bandaging.

This study investigates the effects of early fitting in trans-tibial amputees. The assumption is that compared to elastic bandaging, the use of a rigid dressing in early fitting will result in quicker wound healing and earlier ambulation. A retrospective file search was carried out in three different hospitals, analysing the time to first prosthesis, the incidence of local and general complications and the functional outcome after discharge from hospital. Each of the hospitals used a different method of postoperative care: elastic bandaging, immediate postoperative application of the plaster cast or delayed application of the plaster cast within one week post amputation. In comparison to the elastic bandaging method (N=52), the use of a rigid dressing in the early fitting method (immediate and delayed, N=97) resulted in a statistically significant shorter period from amputation to the delivery of a first regular prosthesis (110 days vs 50 days) and a decreased risk of knee flexion contracture. Although, differences in local complications were not observed, the risk of pressure sores in other places than the stump was increased in early fitting. Instead of further reducing the time to first prosthesis by immediate fitting, the use of delayed fitting resulted in a statistically significant shorter period from amputation to the delivery of a first regular prosthesis (56 vs 40 days). However, delayed fitting was associated with an increased risk for reamputation. In conclusion, this study indicates that early fitting by use of a rigid dressing after trans-tibial amputation is the treatment of choice. If it is possible to apply a plaster cast in the operating room, the authors would prefer the immediate fitting method.