Transcendent Experiences Among Pilgrims to Lourdes: A Qualitative Investigation.

Millions of pilgrims visit Lourdes each year, often seeking revitalisation rather than miraculous cures. We sought to understand the phenomenon of transcendent experiences. We spoke with 67 pilgrims including assisted pilgrims, young volunteers and medical staff. About two in five reported a transcendent experience: some felt they had communicated or had close contact with a divine presence, while others reported a powerful experience of something intangible and otherworldly. Transcendent experiences are an important feature of pilgrimage to Lourdes and the place offers the faithful a means of connecting with the divine, with nature and with the self.

Factors associated with implant survival following total hip replacement surgery: A registry study of data from the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man.

BACKGROUND: Nearly 100,000 people underwent total hip replacement (THR) in the United Kingdom in 2018, and most can expect it to last at least 25 years. However, some THRs fail and require revision surgery, which results in worse outcomes for the patient and is costly to the health service. Variation in the survival of THR implants has been observed between units and reducing this unwarranted variation is one focus of the "Getting it Right First Time" (GIRFT) program in the UK. We aimed to investigate whether the statistically improved implant survival of THRs in a high-performing unit is associated with the implants used or other factors at that unit, such as surgical skill. METHODS AND FINDINGS: We analyzed a national, mandatory, prospective, cohort study (National Joint Registry for England, Wales, Northern Ireland and the Isle of Man [NJR]) of all THRs performed in England and Wales. We included the 664,761 patients with records in the NJR who have received a stemmed primary THR between 1 April 2003 and 31 December 2017 in one of 461 hospitals, with osteoarthritis as the only indication. The exposure was the unit (hospital) in which the THR was implanted. We compared survival of THRs implanted in the "exemplar" unit with THRs implanted anywhere else in the registry. The outcome was revision surgery of any part of the THR construct for any reason. Net failure was calculated using Kaplan-Meier estimates, and adjusted analyses employed flexible parametric survival analysis. The mean age of patients contributing to our analyses was 69.9 years (SD 10.1), and 61.1% were female. Crude analyses including all THRs demonstrated better implant survival at the exemplar unit with an all-cause construct failure of 1.7% (95% CI 1.3-2.3) compared with 2.9% (95% CI 2.8-3.0) in the rest of the country after 13.9 years (log-rank test P < 0.001). The same was seen in analyses adjusted for age, sex, and American Society of Anesthesiology (ASA) score (difference in restricted mean survival time 0.12 years [95% CI 0.07-0.16; P < 0.001]). Adjusted analyses restricted to the same implants as the exemplar unit show no demonstrable difference in restricted mean survival time between groups after 13.9 years (P = 0.34). A limitation is that this study is observational and conclusions regarding causality cannot be inferred. Our outcome is revision surgery, and although important, we recognize it is not the only marker of success of a THR. CONCLUSIONS: Our results suggest that the "better than expected" implant survival results of this exemplar center are associated with implant choice. The survival results may be replicated by adopting key treatment decisions, such as implant selection. These decisions are easier to replicate than technical skills or system factors.

Understanding public perceptions of healing: An arts-based qualitative study.

BACKGROUND: Most healing research has focussed on the views of healers, complementary and alternative medical (CAM) practitioners or medical professionals, and little is known about how the general public conceives of healing. Because healing is a complex and often abstract concept, we addressed this gap in the knowledge using creative qualitative approaches with members of the public. We aimed to elucidate the views of members of the public about their healing, to help offer a better understanding to healthcare professionals. METHODS: Our qualitative arts-based drawing method invited people to respond using crayons and paper to the question 'What does the word healing mean to you?' These drawings were followed by a short recorded interview in which people explained their image. We used convenience sampling to approach members of the public visiting a large wellbeing show and a museum. We analysed images and interviews in tandem using a focus on metaphor. RESULTS: We interviewed 59 people, including three children. Almost two thirds of participants were female. Participants' images and interviews documented three main models of the healing process: i) Healing comes from a great external force, exemplified by the sun; ii) Healing comes from other people, whether medical professionals, CAM practitioners or healers; and iii) Healing comes from within, and the individual has the ability to self-heal. People described practices and inner states that could help achieve healing. Some people depicted more than one model, demonstrating the interlinkages between the models, and some described the outcome of healing (wholeness) rather than the process. CONCLUSIONS: The drawing-based approach encouraged an intuitive way of thinking, capturing concepts that cannot easily be verbalised. Members of the public have nuanced, complex understandings of the concept of healing, and these echo historical and modern concepts of healing and healthcare. The models our participants described often interlink, suggesting an overarching framework for the way people conceive of healing. The findings may be useful both as a guide to further research and as insight that may facilitate healthcare processes.

Mental health in medical students: time to act.

BACKGROUND: Mental health problems are prevalent amongst medical students. However, many students delay seeking medical help or support from the medical school for a variety of reasons, including a fear of facing fitness to practice proceedings. Tackling this problem of awareness and delayed presentation will need a strong and dedicated focus at all stages, with prevention being of great importance. METHODS: A conference dedicated to mental health and well-being was organised for students of all years. The first part of the conference centred on well-being dilemmas and the second part focused on discussing important issues in small group sessions. RESULTS: Students were divided into eight groups and each group suggested improvements to the course that they felt would improve mental health and well-being. The main suggestions raised were: reassurance that the disclosure of mental health problems would not automatically result in fitness to practice proceedings; separate academic and pastoral roles of tutors; open up the topic of mental health and well-being more frequently during the programme; improve knowledge about the availability of support services; and have mentors who are at an earlier stage in postgraduate training (e.g. junior doctors). DISCUSSION: It is necessary to tackle the prevalent myths about this topic. Many students are unaware of the support services available. This conference has therefore sought to increase awareness of the topic. An approach is also now needed to identify those who need extra help. The authors strongly advocate opening up this topic throughout the course in the context of a dedicated conference, for example. Many students are unaware of the support services available The authors strongly advocate opening up this topic throughout the course in the context of a dedicated conference ….

Clients of UK healers: A mixed methods survey of their demography, health problems, and experiences of healing.

BACKGROUND: Healing has not been well researched, and very little is known about who goes to healers, and what they experience. METHODS: A survey of UK-based healers was undertaken with the help of The Confederation of Healing Organisations, asking healers to report on up to 20 consultations. Forms asked about the demography of healer and client, reasons for the consultation, type of healing, and outcomes. Both quantitative and qualitative data were analysed. RESULTS: 278 returned forms from 39 healers (average age 58) were analysed. Healing was described as Spiritual (69%), Reiki (15%) or Energy (10%). The clients had an average age of 57, and 76% were women. The most common reasons for consulting were mental health problems and pain. 93% of the clients reported experiencing immediate benefits. Relaxation, improved wellbeing and relief of pain were often reported. In addition, 76 (27%) had some unusual sensory experiences during the session, such as feelings of warmth, seeing coloured lights, or tingling sensations. The majority of general comments about the experience were positive, and 68% made another appointment. CONCLUSIONS: Older people, particularly older women, are the main recipients of healing in the UK, and they go for help with many problems, particularly mental health issues and pain. The majority have a positive experience, and come back for more. In addition to relief of symptoms, many have sensory experiences which could indicate that some special type of interaction was taking place between healer and healee.

Room for improvement: a randomised controlled trial with nested qualitative interviews on space, place and treatment delivery.

OBJECTIVE: Healthcare-oriented design in hospitals can promote better clinical outcomes. Creating optimal facilities may increase treatment effects. We investigated the influence of the treatment room on effects of exercise therapy. METHODS: In a mixed-method randomised controlled double-blind trial, middle-aged individuals reporting knee or hip pain performed 8 weeks of exercise therapy in (1) a newly built physically enhanced environment, (2) a standard environment or (3) were waitlisted, receiving no intervention. Participants and therapists were blind to study aim. Primary outcome was participants' Global Perceived Effect (GPE; seven-point Likert scale). Six nested focus group interviews with participants (n=25) and individual interviews with therapists (n=2) explored experiences of the environments. RESULTS: 42 people exercised in the physically enhanced environment, 40 in the standard environment, 21 were waitlisted. Contrary to our hypothesis, the treatment response seemed greater in the standard environment for GPE (0.98, 95% CI0.5 to 1.4) than for the physically enhanced environment (0.37, 95% CI -0.2 to 0.9), between-group difference (0.61, 95% CI -0.1 to 1.3) did not reach statistical significance (p=0.07). Waitlist group reported no improvement (-0.05 95% CI -0.5 to 0.4). In interviews, participants from the standard environment expressed greater social cohesion and feeling at home. Qualitative themes identified; reflection, sense of fellowship and transition. Secondary patient-reported outcomes and qualitative findings supported the primary finding, while improvements in muscle strength and aerobic capacity did not differ between exercise groups. CONCLUSION: Results suggest that the physical environment contributes to treatment response. Matching patients' preferences to treatment rooms may improve patient-reported outcomes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT02043613.

One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies.

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.

The characterisation of unexplained pain after knee replacement.

BACKGROUND: The aims of this study were to characterise the pain experienced by patients with chronic pain after knee replacement (KR), in whom no apparent 'orthopaedic' problem could be identified, and to establish how many have pain sensitisation problems (including neuropathic pain). METHODS: A total of 44 patients were prospectively evaluated at a multidisciplinary tertiary referral clinic by an orthopaedic surgeon, pain specialist, rheumatologist and physiotherapist. These patients had been pre-screened by an orthopaedic surgeon to remove cases where there was an obvious cause of pain that could be treated with revision surgery. They were then followed up to find out whether any subsequent interventions had occurred. RESULTS: The mean time since surgery was 29 months (range: 3-108 months), and 18% were revision KR. Patients were evaluated for symptoms of nociceptive pain, allodynia, pains elsewhere and psychosocial factors. The patients were categorised into nociceptive pain 43% (n = 19), pain sensitisation 25% (n = 11) and mixed pain 32% (n = 14). Mean Visual Analogue Score (VAS) pain scores were 6.7/10 with high scores for both constant (66%) and intermittent (70%) pain elements, and pain caused high levels of interference with life. Fifty percent suffered depression and 25% suffered widespread pains (more than three pains elsewhere in the body). Patients with widespread pains suffered more pain (p = 0.01) and higher rates of both pain sensitisation (p = 0.07) and thermal allodynia (p < 0.04). CONCLUSION: Patients after KR can experience severe pain that interferes with their lives, depression and many have pain sensitisation problems rather than any local, nociceptive cause. We advocate screening patients with unexplained pain after KR for pain sensitisation problems, pains at other sites and depression. Appropriate further treatment and multidisciplinary interventions can then be arranged.

Healing journey: a qualitative analysis of the healing experiences of Americans suffering from trauma and illness.

OBJECTIVES: To elucidate pathways to healing for people having suffered injury to the integrity of their function as a human being. METHODS: A team of physician-analysts conducted thematic analyses of in-depth interviews of 23 patients who experienced healing, as identified by six primary care physicians purposefully selected as exemplary healers. RESULTS: People in the sample experienced healing journeys that spanned a spectrum from overcoming unspeakable trauma and then becoming healers themselves to everyday heroes functioning well despite ongoing serious health challenges.The degree and quality of suffering experienced by each individual is framed by contextual factors that include personal characteristics, timing of their initial or ongoing wounding in the developmental life cycle and prior and current relationships.In the healing journey, bridges from suffering are developed to healing resources/skills and connections to helpers outside themselves. These bridges often evolve in fits and starts and involve persistence and developing a sense of safety and trust.From the iteration between suffering and developing resources and connections, a new state emerges that involves hope, self-acceptance and helping others. Over time, this leads to healing that includes a sense of integrity and flourishing in the pursuit of meaningful goals and purpose. CONCLUSION: Moving from being wounded, through suffering to healing, is possible. It is facilitated by developing safe, trusting relationships and by positive reframing that moves through the weight of responsibility to the ability to respond.

The Influence of Arthritis in Other Major Joints and the Spine on the One-Year Outcome of Total Hip Replacement: A Prospective, Multicenter Cohort Study (EUROHIP) Measuring the Influence of Musculoskeletal Morbidity.

BACKGROUND: Although arthritis in other affected major joints and back pain are known to lead to worse outcomes following total hip replacement, to our knowledge, these risk factors have not previously been operationalized as a musculoskeletal morbidity profile. The aim of this study was to measure the influence of other major joints and the spine (as grades of musculoskeletal morbidity) on the 1-year outcome of primary total hip replacement. METHODS: The EUROHIP study consists of 1,327 patients undergoing primary total hip replacement for arthritis across 20 European orthopaedic centers. The primary outcome was the responder rate at 12 months calculated with the relative effect per patient for total hip replacement using the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The primary predictor of interest was different combinations of arthritis of major joints and the spine grouped into 4 musculoskeletal morbidity grades: 1 (single major joint), 2 (multiple major joints), 3 (single major joint and spine), and 4 (multiple major joints and spine). The confounders adjusted for were age, sex, body mass index, living situation, years of hip pain, American Society of Anesthesiologists (ASA) class, anxiety or depression, and preoperative WOMAC subscales. RESULTS: For this analysis, 845 patients were included with complete 12-month follow-up WOMAC scores. The mean patient age was 65.7 years, and 55.2% of patients were female. CONCLUSIONS: The involvement of other major joints and the spine assessed as 1 of 4 musculoskeletal morbidity grades had a strong influence on the 1-year outcome after total hip replacement. The effect size was large compared with other risk factors. Even so, the majority of patients in musculoskeletal morbidity grade 4 had favorable outcomes from the surgical procedure (>74% response to surgical procedures). LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Transformational Changes in Health Status: A Qualitative Exploration of Healing Moments.

BACKGROUND AND AIMS: Dramatic self-change is a familiar concept within religious experience and is recognized within psychotherapy and some fields of nursing. However, it has been given limited consideration in wider health research, including healing research. We sought to explore the phenomenon of "healing moments". METHODS: Alternative medicine practitioners attending a continuing professional development course for healers within the UK's Holistic Health Show were shown a 10min video clip showing two of the authors discussing healing moments. Sixty-nine (69) of the practitioners then provided "short stories" outlining their own experiences of such moments. Both the video and the short stories were analyzed qualitatively using a thematic approach. We sought to evaluate holistic practitioners' perceptions of the concept of healing moments. RESULTS: The concept of healing moments was widely accepted by the 69 participants. An overarching theme of transformational change described personal shifts that ranged from the sudden and quasimiraculous to transient but much-needed improvements in health and wellbeing. Three subordinate themes of connectivity, quiescence and control were identified. Connectivity described intense connections, experienced through touch, empathy and love, which could provide reciprocal benefits for healers as well as clients. Quiescence captured the quiet, calm atmosphere that pervaded many healing episodes. The contrasting aspects of control encompassed healers relinquishing control to channel healing, and clients seizing control to become empowered in their own healing process. CONCLUSION: Healing moments are a recognized and distinct concept within healing, although they remain under-explored in the literature. Our findings suggest that such experiences are common among alternative medicine practitioners. The concepts we uncovered can inform future research.

Western medical acupuncture in a group setting for knee osteoarthritis: results of a pilot randomised controlled trial.

BACKGROUND: Evidence suggests acupuncture may be effective for treating the symptoms of knee osteoarthritis. Offering this in a group setting may offer cost savings. The aim of this study was to establish the feasibility of a definitive trial to assess the clinical and cost-effectiveness of Western medical acupuncture given in groups, or given individually, for adults with severe knee pain attributable to osteoarthritis. METHODS: A pilot randomised controlled trial (RCT) was conducted. Participants were recruited from seven general practices in Plymouth, Devon. Acupuncture was provided, at a dosage that increased up to and including electroacupuncture if no pain relief was reported, by one experienced acupuncturist in a community clinic. Potentially eligible adults aged at least 45 years with knee osteoarthritis were identified from practice registers, screened and randomised to either: (1) standardised advice and exercise booklet alone ('standard'); (2) booklet plus group acupuncture ('group'); and (3) booklet plus individual acupuncture ('individual'). Both acupuncture arms received up to ten treatments over 12 weeks. Recruitment, retention and data completion rates were recorded, and participants completed questionnaires on acceptability. We collected pain, stiffness and function data (using the Western Ontario McMaster Universities Osteoarthritis Index; WOMAC) and general health (EQ-5D) and economic measures at baseline and 14 weeks post-randomisation. RESULTS: We screened 149 people and randomised 60 (40 %), 20 per arm. The overall 14 week follow-up rate was 77 %, but only 70 % in the 'standard' group; 4.1 % of data points were missing. The study was acceptable to participants. Changes in WOMAC pain score (intention to treat complete case analysis) from baseline to 14 week follow-up were: 'standard', 0.4 (95 % confidence interval (CI) -1.4, 2.2, n = 14); 'group' -3.2 (95 % CI -5.1, -1.4, n = 17); 'individual' -2.4 (95 % CI -4.1, -0.7, n = 15). CONCLUSIONS: A definitive three-arm trial is feasible. Further follow-up reminders, minimum data collection and incentives should be considered to improve participant retention in the follow-up processes in the standardised advice and exercise booklet arm. TRIAL REGISTRATION: ISRCTN05305406.

Review of 99 self-report measures for assessing well-being in adults: exploring dimensions of well-being and developments over time.

OBJECTIVE: Investigators within many disciplines are using measures of well-being, but it is not always clear what they are measuring, or which instruments may best meet their objectives. The aims of this review were to: systematically identify well-being instruments, explore the variety of well-being dimensions within instruments and describe how the production of instruments has developed over time. DESIGN: Systematic searches, thematic analysis and narrative synthesis were undertaken. DATA SOURCES: MEDLINE, EMBASE, EconLit, PsycINFO, Cochrane Library and CINAHL from 1993 to 2014 complemented by web searches and expert consultations through 2015. ELIGIBILITY CRITERIA: Instruments were selected for review if they were designed for adults (≥18 years old), generic (ie, non-disease or context specific) and available in an English version. RESULTS: A total of 99 measures of well-being were included, and 196 dimensions of well-being were identified within them. Dimensions clustered around 6 key thematic domains: mental well-being, social well-being, physical well-being, spiritual well-being, activities and functioning, and personal circumstances. Authors were rarely explicit about how existing theories had influenced the design of their tools; however, the 2 most referenced theories were Diener's model of subjective well-being and the WHO definition of health. The period between 1990 and 1999 produced the greatest number of newly developed well-being instruments (n=27). An illustration of the dimensions identified and the instruments that measure them is provided within a thematic framework of well-being. CONCLUSIONS: This review provides researchers with an organised toolkit of instruments, dimensions and an accompanying glossary. The striking variability between instruments supports the need to pay close attention to what is being assessed under the umbrella of 'well-being' measurement.

One-stage or two-stage revision surgery for prosthetic hip joint infection--the INFORM trial: a study protocol for a randomised controlled trial.

BACKGROUND: Periprosthetic joint infection (PJI) affects approximately 1% of patients following total hip replacement (THR) and often results in severe physical and emotional suffering. Current surgical treatment options are debridement, antibiotics and implant retention; revision THR; excision of the joint and amputation. Revision surgery can be done as either a one-stage or two-stage operation. Both types of surgery are well-established practice in the NHS and result in similar rates of re-infection, but little is known about the impact of these treatments from the patient's perspective. The main aim of this randomised controlled trial is to determine whether there is a difference in patient-reported outcome measures 18 months after randomisation for one-stage or two-stage revision surgery. METHODS/DESIGN: INFORM (INFection ORthopaedic Management) is an open, two-arm, multi-centre, randomised, superiority trial. We aim to randomise 148 patients with eligible PJI of the hip from approximately seven secondary care NHS orthopaedic units from across England and Wales. Patients will be randomised via a web-based system to receive either a one-stage revision or a two-stage revision THR. Blinding is not possible due to the nature of the intervention. All patients will be followed up for 18 months. The primary outcome is the WOMAC Index, which assesses hip pain, function and stiffness, collected by questionnaire at 18 months. Secondary outcomes include the following: cost-effectiveness, complications, re-infection rates, objective hip function assessment and quality of life. A nested qualitative study will explore patients' and surgeons' experiences, including their views about trial participation and randomisation. DISCUSSION: INFORM is the first ever randomised trial to compare two widely accepted surgical interventions for the treatment of PJI: one-stage and two-stage revision THR. The results of the trial will benefit patients in the future as the main focus is on patient-reported outcomes: pain, function and wellbeing in the long term. Patients state that these outcomes are more important than those that are clinically derived (such as re-infection) and have been commonly used in previous non-randomised studies. Results from the INFORM trial will also benefit clinicians and NHS managers by enabling the comparison of these key interventions in terms of patients' complication rates, health and social resource use and their overall cost-effectiveness. TRIAL REGISTRATION: Current controlled trials ISRCTN10956306 (registered on 29 January 2015); UKCRN ID 18159.

Trajectories of Pain and Function after Primary Hip and Knee Arthroplasty: The ADAPT Cohort Study.

BACKGROUND AND PURPOSE: Pain and function improve dramatically in the first three months after hip and knee arthroplasty but the trajectory after three months is less well described. It is also unclear how pre-operative pain and function influence short- and long-term recovery. We explored the trajectory of change in function and pain until and beyond 3-months post-operatively and the influence of pre-operative self-reported symptoms. METHODS: The study was a prospective cohort study of 164 patients undergoing primary hip (n = 80) or knee (n = 84) arthroplasty in the United Kingdom. Self-reported measures of pain and function using the Western Ontario and McMaster Universities Osteoarthritis index were collected pre-operatively and at 3 and 12 months post-operatively. Hip and knee arthroplasties were analysed separately, and patients were split into two groups: those with high or low symptoms pre-operatively. Multilevel regression models were used for each outcome (pain and function), and the trajectories of change were charted (0-3 months and 3-12 months). RESULTS: Hip: Most improvement occurred within the first 3 months following hip surgery and patients with worse pre-operative scores had greater changes. The mean changes observed between 3 and twelve months were statistically insignificant. One year after surgery, patients with worse pre-operative scores had post-operative outcomes similar to those observed among patients with less severe pre-operative symptoms. Knee: Most improvement occurred in the first 3 months following knee surgery with no significant change thereafter. Despite greater mean change during the first three months, patients with worse pre-operative scores had not 'caught-up' with those with less severe pre-operative symptoms 12 months after their surgery. CONCLUSION: Most symptomatic improvement occurred within the first 3 months after surgery with no significant change between 3-12 months. Further investigations are now required to determine if patients with severe symptoms at the time of their knee arthroplasty have a different pre-surgical history than those with less severe symptoms and if they could benefit from earlier surgical intervention and tailored rehabilitation to achieve better post-operative patient-reported outcomes.

Associations between pre-operative radiographic osteoarthritis severity and pain and function after total hip replacement : Radiographic OA severity predicts function after THR.

UNLABELLED: Total hip replacement (THR) is an effective procedure for alleviating pain and improving function in majority of patients with end-stage osteoarthritis (OA). Clinically, meaningful improvement in pain and function after surgery is not universal, and the reasons for this are unclear. We investigated whether radiographic OA severity was a determinant of pain and disability experienced by patients after THR. The Harris hip score (HHS) was collected pre-operatively and at 1 and 2 years after primary THR (N = 382). The main independent variable was the modified Kellgren-Lawrence grade, which was assessed from the pre-operative radiographs. The outcome variable was response to surgery at 1 and 2 years. The minimum important difference (MID) in the HHS pain and function scores were used to determine response to surgery. This was based on achieving half the standard deviation in change in scores at 1 year. Regression models were created to assess the relationships between pre-operative x-ray findings and pain and function. Based on the MID, 96.2 and 95.5% of patients demonstrated an improvement in pain, and 81.2 and 78.3% of patients demonstrated an improvement in function at 1 and 2 years. Odds ratios for demonstrating an MID in both pain and functions scores for patients with less severe baseline radiographic changes were significantly lower at 1 and 2 years when compared to those with severe radiographic changes. Patients with less severe pre-operative radiographic hip damage are least likely to have substantial gains in terms of pain relief and improved function as a result of a THR. LEVEL OF EVIDENCE: Level III, prognostic study.

Rest Pain and Movement-Evoked Pain as Unique Constructs in Hip and Knee Replacements.

OBJECTIVE: There is limited information about the extent to which the association between preoperative and chronic postoperative pain is mediated via pain-on-movement or pain-at-rest. We explored these associations in patients undergoing total hip replacement (THR) and total knee replacement (TKR). METHODS: A total of 322 and 316 patients receiving THR and TKR, respectively, were recruited into a single-center UK cohort (Arthroplasty Pain Experience) study. Preoperative, acute postoperative, and 12-month pain severity was measured using self-reported pain instruments. The association between preoperative/acute pain and chronic postoperative pain was investigated using structural equation modeling (SEM). RESULTS: Patients with high levels of preoperative pain were more likely to report chronic pain after THR (ß = 0.195, P = 0.02) and TKR (ß = 0.749, P < 0.0001). Acute postoperative pain-on-movement was not associated with chronic pain after TKR or THR after adjusting for preoperative pain; however, acute pain-at-rest was associated with chronic pain after THR (ß = 0.20, P < 0.0002) but not TKR after adjusting for preoperative pain. Analysis of pain-at-rest and pain-on-movement highlighted differences between THR and TKR patients. Chronic pain-at-rest after THR was weakly associated with pain-at-rest during the preoperative (ß = 0.11, P = 0.068) and acute postoperative period (ß = 0.21, P < 0.0001). In contrast, chronic pain-on-movement after TKR was strongly associated with the severity of pain-on-movement during the preoperative period (ß = 0.51, P = 0.001). CONCLUSION: SEM illustrated the different patterns of association between measures of pain over time in patients undergoing THR and TKR for osteoarthritis. These findings highlight the importance of future work that explores the mechanisms underlying pain-on-movement and pain-at-rest.

A Consideration of the Perspectives of Healing Practitioners on Research Into Energy Healing.

Energy healing is a complex intervention with the purpose of enhancing wholeness within the client. Approaches to complex interventions require thoughtful utilization of a wide range of research methods. In order to advance the research in this field, we sought to understand the healing practitioners' point of view by reviewing qualitative literature, research reviews, and commentary written by and about practitioners. Further, we conducted a brief survey among healers, asking their opinions on types and topics of research in this field. Emerging from this inquiry is an overview of the healers' state required for successful healing, the importance of the clients' contribution, the heterogeneity of the process of healing, and the importance of choosing appropriate outcomes to reflect the goal of wholeness. Beyond attending to measurement of these nuanced aspects, we propose utilization of research designs appropriate for complex interventions, more use of qualitative research techniques, consideration of large data registries, and adoption of the perspectives of realist research. An important gap identified was the overall lack of understanding of the clients' experience and contribution to the healing encounter.