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1.
J Orthop Sports Phys Ther ; 51(4): 188-195, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33789433

RESUMO

OBJECTIVE: To assess whether an exercise and education program was more effective than an education booklet for preventing recurrence of low back pain (LBP). DESIGN: Randomized controlled trial. METHODS: Participants aged 18 years or older who had recovered from an episode of LBP within the previous week were recruited from primary care practices and the community. Participants were randomized to receive either 12 weeks of exercise and education (8 supervised exercise sessions and 3 one-on-one sessions) or a control (education booklet). The primary outcome was time to recurrence of LBP during the 1-year follow-up. Times to recurrence of LBP leading to activity limitation, care seeking, and work absence were secondary outcomes. Data were analyzed with Cox regression using intention-to-treat principles. RESULTS: We planned to include 160 participants but included 111 (exercise and education, n = 57; educational booklet, n = 54). At the end of the study period, data completeness was 84.2%. Thirty-six (63%) participants in the exercise and education group and 31 (57%) participants in the control group had a recurrence of LBP. There was no statistically significant difference in time to recurrence of pain between groups (hazard ratio = 1.09; 95% confidence interval: 0.7, 1.8). There was no statistically significant effect for any of the secondary outcomes. CONCLUSION: Among people recently recovered from LBP, exercise and education may not meaningfully reduce risk of recurrence compared to providing an educational booklet. J Orthop Sports Phys Ther 2021;51(4):188-195. doi:10.2519/jospt.2021.10187.

2.
Pain ; 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-33769364

RESUMO

ABSTRACT: Deprescribing opioids has been identified as an intervention to mitigate opioid harm, however, it is often challenging to implement interventions and communicate deprescribing decisions to consumers. The development of opioid deprescribing guidelines may provide guidance and support on when and how to reduce or cease opioids in routine care. This study aimed to explore the perspectives of opioid consumers on opioid deprescribing and determine factors to be considered in the development of opioid deprescribing guidelines. A purposive sample of twenty consumers using opioids for pain were recruited. Semi-structured interviews were conducted, audio recorded and transcribed verbatim. Inductive thematic analysis was undertaken, followed by a framework analysis informed by Bandura's Social Cognitive Theory. Behavioral, cognitive and environmental factors influence consumers' attitudes and actions regarding opioid deprescribing. Significant barriers to opioid deprescribing were identified, including fears of pain and withdrawal effects, opioid related stigma, and perceived inadequacies of the healthcare system. Improved communication between healthcare professionals and consumers regarding expectations of deprescribing and goals of care, as well as the provision of greater opportunities for consumer engagement in decision making were identified as avenues to improve the success of opioid deprescribing. For opioid deprescribing guidelines to be effective and achieve the intended goal of optimizing opioid use, consumers need to feel empowered to engage in opioid reduction or cessation. The findings of this study may facilitate a patient-centred approach for practitioners and guideline developers in creating recommendations and interventions to enable opioid deprescribing through targeting behavioral change.

3.
BMJ ; 372: m4825, 2021 01 20.
Artigo em Inglês | MEDLINE | ID: mdl-33472813

RESUMO

OBJECTIVE: To investigate the efficacy and safety of antidepressants for back and osteoarthritis pain compared with placebo. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, International Pharmaceutical Abstracts, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to 15 November and updated on 12 May 2020. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials comparing the efficacy or safety, or both of any antidepressant drug with placebo (active or inert) in participants with low back or neck pain, sciatica, or hip or knee osteoarthritis. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data. Pain and disability were primary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability). A random effects model was used to calculate weighted mean differences and 95% confidence intervals. Safety (any adverse event, serious adverse events, and proportion of participants who withdrew from trials owing to adverse events) was a secondary outcome. Risk of bias was assessed with the Cochrane Collaboration's tool and certainty of evidence with the grading of recommendations assessment, development and evaluation (GRADE) framework. RESULTS: 33 trials (5318 participants) were included. Moderate certainty evidence showed that serotonin-noradrenaline reuptake inhibitors (SNRIs) reduced back pain (mean difference -5.30, 95% confidence interval -7.31 to -3.30) at 3-13 weeks and low certainty evidence that SNRIs reduced osteoarthritis pain (-9.72, -12.75 to -6.69) at 3-13 weeks. Very low certainty evidence showed that SNRIs reduced sciatica at two weeks or less (-18.60, -31.87 to -5.33) but not at 3-13 weeks (-17.50, -42.90 to 7.89). Low to very low certainty evidence showed that tricyclic antidepressants (TCAs) did not reduce sciatica at two weeks or less (-7.55, -18.25 to 3.15) but did at 3-13 weeks (-15.95, -31.52 to -0.39) and 3-12 months (-27.0, -36.11 to -17.89). Moderate certainty evidence showed that SNRIs reduced disability from back pain at 3-13 weeks (-3.55, -5.22 to -1.88) and disability due to osteoarthritis at two weeks or less (-5.10, -7.31 to -2.89), with low certainty evidence at 3-13 weeks (-6.07, -8.13 to -4.02). TCAs and other antidepressants did not reduce pain or disability from back pain. CONCLUSION: Moderate certainty evidence shows that the effect of SNRIs on pain and disability scores is small and not clinically important for back pain, but a clinically important effect cannot be excluded for osteoarthritis. TCAs and SNRIs might be effective for sciatica, but the certainty of evidence ranged from low to very low. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020158521.


Assuntos
Antidepressivos/uso terapêutico , Dor nas Costas/tratamento farmacológico , Osteoartrite/tratamento farmacológico , Ciática/tratamento farmacológico , Inibidores da Recaptação de Serotonina e Norepinefrina/uso terapêutico , Antidepressivos/classificação , Humanos , Manejo da Dor/métodos
4.
Pain Med ; 2020 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-33164087

RESUMO

OBJECTIVE: To review studies examining the proportion of people with chronic noncancer pain who report consuming opioids and characteristics associated with their use. DESIGN: Systematic review. METHODS: We searched databases from inception to February 8, 2020, and conducted citation tracking. We included observational studies reporting the proportion of adults with chronic noncancer pain who used opioid analgesics. Opioids were categorized as weak (e.g., codeine) or strong (e.g., oxycodone). Study risk of bias was assessed, and Grading of Recommendations Assessment, Development and Evaluations provided a summary of the overall quality. Results were pooled using a random-effects model. Meta-regression determined factors associated with opioid use. RESULTS: Sixty studies (N=3,961,739) reported data on opioid use in people with chronic noncancer pain from 1990 to 2017. Of these 46, 77% had moderate risk of bias. Opioid use was reported by 26.8% (95% confidence interval [CI], 23.1-30.8; moderate-quality evidence) of people with chronic noncancer pain. The use of weak opioids (17.3%; 95% CI 11.9-24.4; moderate-quality evidence) was more common than the use of strong opioids (9.8%; 95% CI, 6.8-14.0; low-quality evidence). Meta-regression determined that opioid use was associated with geographic region (P=0.02; lower in Europe than North America), but not sampling year (P=0.77), setting (P=0.06), diagnosis (P=0.34), or disclosure of funding (P=0.77). CONCLUSIONS: Our review summarized data from over 3.9 million people with chronic noncancer pain reporting their opioid use. Between 1990 and 2017, one-quarter of people with chronic noncancer pain reported taking opioids, and this proportion did not change over time.

5.
BMC Musculoskelet Disord ; 21(1): 734, 2020 Nov 10.
Artigo em Inglês | MEDLINE | ID: mdl-33172435

RESUMO

BACKGROUND: The aim of this study is to introduce a new method of percutaneous endoscopic decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative kyphoscoliosis patients without instability or those who with multiple comorbidities. Decompression alone using endoscope for kyphoscoliosis patient is technical demanding and may result in unnecessary bone destruction leading to further instability. The O-arm/StealthStation system is popular for its ability to provide automated registration with intraoperative, postpositioning computed tomography (CT) which results in superior accuracy in spine surgery. METHODS: In this study, we presented four cases. All patients were over seventy years old female with variable degrees of kyphoscoliosis and multiple comorbidities who could not endure major spine fusion surgery. Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation were successfully performed. Patients' demographics, image study parameters, and outcome measurements including pre- and post-operative serial Visual analog scale (VAS), and Oswestry Disability Index (ODI) were well documented. The follow-up time was 1 year. RESULTS: Pre- and post-operative MRI showed average dural sac cross sectional area (DSCSA) improved from 81.62 (range 67.34-89.07) to 153.27 (range 127.96-189.73). Preoperative neurological symptoms including radicular leg pain improved postoperatively. The mean ODI (%) were 85 (range 82.5-90) at initial visit, 35.875 (range 25-51) at 1 month post-operatively, 26.875 (range 22.5-35) at 6 months post-operatively and 22.5 (range 17.5-30) at 12 months post-operatively (p < 0.05). The mean VAS score were 9 (range 8-10) at initial visit, 2.25 (range 2-3) at 1 month post-operatively, 1.75 (range 1-2) at 6 months post-operatively and 0.25 (range 0-1) at 12 months post-operatively (p < 0.05). There was no surgery-related complication. CONCLUSIONS: To the best of our knowledge, this is the first preliminary study of percutaneous endoscopic laminotomy under O-arm navigation with successful outcomes. The innovative technique may serve as a promising solution in treating spinal stenosis patients with lumbar kyphoscoliosis and multiple comorbidities.

6.
J Physiother ; 66(4): 249-255, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33172627

RESUMO

QUESTION: Do program and participant characteristics influence people's willingness to undertake exercise programs to prevent recurrence of low back pain? DESIGN: Discrete choice experiment. PARTICIPANTS: Six hundred and forty-seven people with a recent history of low back pain. DATA COLLECTION: Recruitment and participation occurred online. Participants were randomised to a block of 10 choice tasks, where the characteristics of the exercise program varied systematically. The characteristics that were presented for each exercise program were mode of exercise delivery, mode of supervision, setting, duration, weekly frequency, travel time, risk of recurrence, and costs. For each choice task, participants chose between no program or an exercise program with the characteristics as presented. DATA ANALYSIS: Choices were analysed using mixed logit models. Latent class models examined preference heterogeneity and identified participant-level characteristics predictive of preferences. RESULTS: There appeared to be an underlying preference for exercise compared with no exercise, all else being equal. Preferences for programs were significantly influenced by the characteristics of the programs. Participants were less likely to choose exercise when programs were of a longer duration (OR 0.92, 95% CI 0.89 to 0.96 per extra month), but more likely to prefer programs offering greater reduction in the risk of recurrence of low back pain (OR 3.91, 95% CI 3.20 to 4.79 per 10% reduction in risk of recurrence). Preferences for engaging in exercise programs to prevent recurrent of low back pain were influenced by the characteristics of the programs themselves. However, there was mismatch between the preferred characteristics of exercise programs and the characteristics of known effective programs. CONCLUSION: People who have had low back pain should be advised explicitly about which exercise programs reduce recurrence. Understanding low back pain patients' preferences can help inform the implementation of existing prevention programs and guide the design of new prevention programs.

7.
J Orthop Sports Phys Ther ; 50(11): 597-606, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33131394

RESUMO

OBJECTIVE: To evaluate the effect of walking promotion strategies on physical activity, pain, and function in people with musculoskeletal disorders. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We performed the searches in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Physiotherapy Evidence Database (PEDro) from inception to August 2019. STUDY SELECTION CRITERIA: We included randomized controlled trials evaluating interventions that promote walking in people with musculoskeletal disorders. DATA SYNTHESIS: We used the PEDro scale for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence. We expressed pooled effects for between-group differences as mean differences or standardized mean differences and 95% confidence intervals, or as risk ratios and 95% confidence intervals, using random-effects meta-analyses. RESULTS: Twelve eligible trials (n = 1456 participants) were identified. There was moderate- to very low-quality evidence of no difference in physical activity levels for walking promotion interventions when compared to minimal interventions, and a significant effect favoring walking promotion when compared with usual care in the short term. There was moderate-quality evidence that walking promotion was modestly effective for reducing pain and improving function compared with minimal intervention and usual care. There was no difference in pain and function for walking promotion compared to supervised exercise. Walking promotion was not associated with different rates of adverse events compared to control conditions. CONCLUSION: Strategies to promote walking did not increase physical activity in people with musculoskeletal disorders. Walking promotion was associated with small improvements in pain and function compared to minimal intervention and usual care. J Orthop Sports Phys Ther 2020;50(11):597-606. doi:10.2519/jospt.2020.9666.

8.
BMJ Open ; 10(10): e037149, 2020 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-33033088

RESUMO

INTRODUCTION: Low back pain (LBP) is recognised globally as a prevalent, costly and disabling condition. Recurrences are common and contribute to much of the burden of LBP. Current evidence favours exercise and education for prevention of LBP recurrence, but an optimal intervention has not yet been established. Walking is a simple, widely accessible, low-cost intervention that has yet to be evaluated. This randomised controlled trial (RCT) aims to establish the effectiveness and cost-effectiveness of a progressive and individualised walking and education programme (intervention) for the prevention of LBP recurrences in adults compared with no treatment (control). METHODS AND ANALYSIS: A pragmatic, two-armed RCT comparing walking and education (n=349) with a no treatment control group (n=349). Inclusion criteria are adults recovered from an episode of non-specific LBP within the last 6 months. Those allocated to the intervention group will receive six sessions (three face to face and three telephone delivered) with a trained physiotherapist to facilitate a progressive walking programme and education over a 6-month period. The primary outcome will be days to first recurrence of an episode of activity-limiting LBP. The secondary outcomes include days to recurrence of an episode of LBP, days to recurrence of an episode of LBP leading to care seeking, disability and quality of life measured at 3, 6, 9 and 12 months and costs associated with LBP recurrence. All participants will be followed up monthly for a minimum of 12 months. The primary intention-to-treat analysis will assess difference in survival curves (days to recurrence) using the log-rank statistic. The cost-effectiveness analysis will be conducted from the societal perspective. ETHICS AND DISSEMINATION: Approved by Macquarie University Human Research Ethics Committee (Reference: 5201949218164, May 2019). Findings will be disseminated through publication in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12619001134112.

10.
Eur Spine J ; 2020 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-32970236

RESUMO

PURPOSE: To estimate the healthcare resource utilisation of an Australian cohort of people with sciatica and explore individual-level factors associated with expenditure. METHODS: Healthcare utilisation (services and medication) data from a randomised, double-blind, placebo-controlled trial of pregabalin in patients with sciatica (n = 185) were analysed to estimate healthcare expenditure of participants over 12 months. Associations between key baseline socio-economic, pain and quality of life characteristics and healthcare expenditure were examined using generalised linear imputation models. RESULTS: On average, participants accessed AUD$1,134 of healthcare over the year, predominantly made up of $114 of medication and $914 of health services, which included $418 of physiotherapy services. Participants randomised to receive pregabalin incurred higher expenditure ($1,263 compared to $1,001 for placebo), which was largely driven by pregabalin ($158) and greater health services ($107). Healthcare expenditure was significantly higher for participants prescribed pregabalin, earning greater than $1,700 per week ($88,400 per year) and reporting poorer quality of life (physical and mental). CONCLUSION: Our results suggest inefficiency in the use of healthcare resources due to increased healthcare resource utilisation in people with sciatica treated with pregabalin, compared to placebo. Costs of treating sciatica varied based on individual quality of life and socio-economic characteristics.

11.
Drugs ; 80(15): 1563-1576, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32737739

RESUMO

BACKGROUND: Deprescribing, the process of reducing or discontinuing unnecessary or harmful medicines is an essential part of clinical practice. OBJECTIVE: To evaluate the efficacy of interventions designed to deprescribe opioid analgesics for pain relief in patients with chronic non-cancer pain. METHODS: We searched electronic databases, including clinical trial registries, from database inception to 13th January 2020 without restrictions, and conducted citation tracking. Our systematic review included randomised controlled trials (RCTs) evaluating interventions reducing the prescription, or use of opioid analgesics in patients with chronic pain versus control. Inventions could be aimed at the patient, clinician, or both. We excluded trials enrolling patients with cancer or illicit drug use. Two authors independently screened and extracted data. Outcome follow-up timepoints were short (≤ 3 months), intermediate (> 3 but < 12 months) or long (≥ 12 months) term. Primary outcome was the reduction in opioid dose [morphine milligram equivalent (MME) mg/day]. Methodological quality was assessed using the Cochrane Risk of Bias Tool. RESULTS: We included ten patient-focused RCT interventions (n = 835; median 37 participants) and 2 testing clinician-focused interventions (n = 291 clinicians); none at low risk of bias. Patient-focused interventions did not reduce opioid dose in the intermediate term [e.g. dose reduction protocol, mean difference (MD) - 19.9 MME, 95% CI - 107.5 to 67.7], nor did they increase the number of participants who ceased their dose, or increase the risk of serious adverse events or adverse events. One clinician intervention of education plus decision tools versus decision tools alone reduced the number of opioid prescriptions (risk difference (RD) - 0.1, 95% CI - 0.2 to - 0.1), dose (MD - 5.3 MME, 95% CI - 6.2 to - 4.5) and use (RD - 0.1, 95% CI - 0.1 to - 0.0) in the long term. LIMITATIONS: Study heterogeneity prevented meta-analysis. CONCLUSION: The small number of studies and heterogeneity prevented firm conclusions to recommend any one opioid-analgesic-deprescribing strategy in patients with chronic pain. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42017068422.

12.
BMJ Open ; 10(6): e040559, 2020 06 23.
Artigo em Inglês | MEDLINE | ID: mdl-32580990

RESUMO

INTRODUCTION: Sciatica is a lower spine condition characterised by radiating leg pain below the knee. It may be accompanied by motor and sensory loss in the distribution of a spinal nerve. There are few effective treatments for sciatica. Orally administered glucocorticoids have shown some promise, however, any beneficial effects need to be confirmed and weighed against drug safety and cost-effectiveness, in a high-quality, definitive trial. METHODS AND ANALYSIS: The Oral Steroids In Sciatica (OASIS) trial is a randomised, placebo-controlled, double-blind trial that will evaluate a tapering regimen of oral prednisolone in 200 participants with acute sciatica. Participants will be recruited on presentation to general practice, specialist outpatient clinics or hospital emergency departments and randomised to receive orally administered prednisolone 50 mg per day, up to 3 days then tapering to cessation over 10 days, or placebo, for a maximum of 13 days, in addition to guideline advice. Participants will be followed for 1 year. The primary endpoint will be leg pain intensity at 2 weeks. Secondary outcomes will include back pain intensity, disability, time to recovery, quality of life and treatment success rate. Adverse events will be assessed and a cost-effectiveness analysis will be conducted. ETHICS AND DISSEMINATION: Ethical approval has been granted from the Human Research Ethics Committee, The University of Sydney. Trial results will be disseminated by publications and conference presentations and via the media. TRIAL REGISTRATION NUMBER: ACTRN12619001716156.

13.
Braz J Phys Ther ; 24(4): 373-380, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32451161

RESUMO

BACKGROUND: This a priori statistical analysis plan describes the methods of analysis for the Trial Of Prevention Strategies for low back pain (TOPS). OBJECTIVES: TOPS aimed to investigate the effectiveness and cost-effectiveness of exercise and education classes compared with a minimal intervention control in preventing recurrence of low back pain (LBP) in people who have recently recovered from an episode of LBP. METHODS: TOPS is a superiority, pragmatic, parallel-group randomized controlled trial with allocation concealment, blinded outcome assessors, and intention-to-treat analysis. Participants were randomized to a physical therapist-led exercise and education program for 12 weeks or minimal intervention. The primary outcome was days to recurrence of an episode of LBP. The three key secondary outcomes were days to recurrence of an episode of LBP resulting in (1) activity limitation, (2) care seeking for LBP; and (3) work absence of at least 1 day. Differences in survival curves for the primary (days to recurrence) and secondary outcome (days to LBP with activity limitation, days to care seeking due to LBP, and days to work absence due to LBP) will be compared using Cox regression. Hazard ratios (HRs) and median survival times with 95% confidence intervals (CI) will be calculated. The number of adverse events, including serious adverse events will be reported and the proportion of adverse events between groups will be compared using a Chi-squared test. DISCUSSION: This paper will provide a detailed description of the planned analyses for the TOPS trial. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12615000939594).


Assuntos
Exercício Físico/fisiologia , Dor Lombar/fisiopatologia , Austrália , Análise Custo-Benefício , Humanos , Avaliação de Resultados em Cuidados de Saúde , Resultado do Tratamento
16.
Clin J Pain ; 36(7): 505-515, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32217847

RESUMO

OBJECTIVE: The meaning of recovery from musculoskeletal injury is complex, and understanding recovery from whiplash may be particularly important, given the chronic, often recalcitrant nature of the condition. Gaining a better understanding of recovery may also aid in the development and interpretation of future clinical trials. The aim of this study was to define the meaning of recovery from whiplash, and the factors influencing recovery, by exploring the perceptions of people with chronic whiplash, and their treating physiotherapists. MATERIALS AND METHODS: This qualitative study was embedded within a larger randomized-controlled trial, and consisted of semistructured interviews. Interviews were conducted with 13 patient participants with chronic whiplash and 7 physiotherapists. Patient participants were asked what recovery meant to them, and perceptions around barriers and facilitators to recovery were explored. Physiotherapists were also asked to share their beliefs on the meaning of recovery, and what they believe recovery means to their patients. RESULTS: Both patient participants and physiotherapists perceived recovery to be defined within the themes of pain, function, and emotional well-being. Patient participants also identified self-perception as important, whereas physiotherapists identified ownership on the part of the patient, and the multidimensional nature of recovery, including cultural values and beliefs, as important. Several themes relating to barriers and facilitators to recovery were also identified, and included personal and social characteristics and aspects of the therapeutic relationship. DISCUSSION: Recovery is a multidimensional and complex construct. In addition to pain intensity and disability, measurement and conceptualization of recovery should focus on emotional well-being, self-perception, and the cultural values and beliefs of the individual. A positive therapeutic relationship, with attention to psychological and social influences, appears to be important in facilitating recovery and well-being.

17.
BMJ Qual Saf ; 2020 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-32220937

RESUMO

BACKGROUND: Chronic prescription opioid use is a major international public health issue associated with significant harms, including increased risk of hospitalisation, morbidity and death. Guidance for healthcare professionals on when and how to deprescribe or reduce opioids is required. A key step for guideline development for deprescribing pharmacotherapy is to understand the perspectives of stakeholders. The aim of this study was to explore the perspectives of healthcare professional stakeholders on the challenges associated with opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines. METHODS: A qualitative study was undertaken with a purposive sample of healthcare professionals including prescribers, pharmacists and nurses. An initial cohort of participants was identified at the 2018 Australian Deprescribing Network annual meeting and two focus groups were conducted (n=20). Individual interviews were conducted with a further 11 healthcare professionals. Focus groups and interviews were audio-recorded and transcribed verbatim. Data underwent inductive thematic analysis using a phenomenological perspective. RESULTS: Healthcare professionals viewed opioid deprescribing as a challenge and identified several key barriers to deprescribing in clinical practice. Medication, patient, prescriber and health system level challenges were identified. Participants requested evidence-based guidance on the withdrawal of opioid therapies and suggested that prospective opioid deprescribing guidelines require a multitarget, multimodal intervention strategy that addresses patient psychosocial factors and incorporates behavioural change techniques. CONCLUSION: Opioid deprescribing was perceived as a complex and challenging practice with continued prescribing the default behaviour. Evidence-based opioid deprescribing guidelines may be a valuable resource for clinicians to support clinical decision-making and reduce suboptimal opioid use.

18.
J Clin Epidemiol ; 121: 45-54, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31982540

RESUMO

OBJECTIVES: The aim of this study was to reanalyze and reinterpret data obtained in Paracetamol in Acute Low Back Pain (PACE), the first large randomized controlled trial evaluating the efficacy of paracetamol in acute low back pain, to assess the inferential reproducibility of the original conclusions. STUDY DESIGN AND SETTING: Mixed effects models were used to reanalyze pain intensity (primary outcome; 11-point Numeric Rating Scale) and physical functioning, health-related quality of life, sleep quality, and time until recovery (as secondary outcomes), according to the intention-to-treat principle. The original authors of the PACE study were not involved in the development of the methods for this reanalysis. RESULTS: The reproduction analyses indicated no effect of treatment on pain intensity and confidence intervals excluded clinically worthwhile effects (adjusted main effect for regular paracetamol vs. placebo 0.00 [-0.02, 0.01; P = 0.85]; adjusted main effect for paracetamol as-needed vs. placebo 0.00 [-0.02, 0.01; P = 0.92]). Similar results were obtained for all secondary outcomes. CONCLUSION: This study indicates that the conclusions of the PACE trial are inferentially reproducible, even when using a different analytical approach. This reinforces the notion that the management of acute low back pain should focus on providing patients advice and reassurance without the addition of paracetamol.

19.
Eur J Pain ; 24(3): 518-535, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31715647

RESUMO

BACKGROUND: Sciatica can be a debilitating condition and there is limited guidance on the use of glucocorticoids administered via the oral, intramuscular or intravenous route for this condition. These represent viable treatment options in the primary care setting. OBJECTIVE: To evaluate the evidence on efficacy and harms of oral, IM and IV glucocorticoid administration for sciatica. DATABASES AND DATA TREATMENT: MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO (inception to October 2018) were searched for randomised placebo-controlled trials evaluating oral, IV or IM glucocorticoid administration for sciatica. Two authors extracted outcomes data. Continuous pain and disability outcomes were converted to a 0 (no pain/disability) to 100 (worst pain/disability) scale. Data were pooled using a random effects model. Overall quality of evidence was assessed using GRADE. Primary outcomes were leg pain and disability. Primary follow-up period was the immediate-term (<2 weeks from administration). We also considered adverse events. RESULTS: Nine trials were eligible. One study [n = 27] provided low quality evidence of a small reduction in disability with early administration of oral prednisone (within 1 week); MD -13.4 [-23.3, -3.5] but not for pain MD -2.5 [-16.9, 11.9]. There was low quality evidence from one study [n = 78] of moderate reduction in disability and small reduction in pain with early (within 72 hr of symptom onset) single intramuscular administration of methylprednisolone acetate; MD -24.5 [-38.8, -10.2] and -14.0 [-27.4, -0.6], respectively. There were no immediate-term benefits with IV administration. CONCLUSION: The effects of glucocorticoids on immediate-term leg pain or disability are uncertain. Future large high quality trials are needed to resolve this uncertainty.


Assuntos
Glucocorticoides , Ciática , Glucocorticoides/efeitos adversos , Humanos , Perna (Membro) , Ciática/tratamento farmacológico
20.
World Neurosurg ; 135: 197-204, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31706972

RESUMO

BACKGROUND: Surgical interventions for congenital scoliosis are challenging for spine surgeons. The coordination of 3-dimensional (3D), real-time, image-guided navigation with an ultrasonic bone cutter allows surgeons to localize the affected area of the spine accurately and remove the lesion without damaging soft tissue structures. The goal of this technical paper is to report a previously undescribed method of hemivertebrectomy that combines 3D, real-time, image-guided navigation and an ultrasonic bone cutter. We highlight the feasibility and safety of this method in spinal surgery. METHODS: Three patients with congenital scoliosis were treated with this technique. We present three illustrative cases comprising hemivertebrectomies for congenital scoliosis. Intraoperative photos demonstrating the technique are also provided. RESULTS: All surgeries were completed without complications. The hemivertebrae were completely removed, and marked correction of congenital scoliosis was noted. CONCLUSIONS: We believe that the combination of 3D, real-time image navigation and an ultrasonic bone cutter improves hemivertebrectomy by increasing accuracy and avoiding dura laceration, major organ damage, or potential vessel damage.


Assuntos
Imageamento Tridimensional/métodos , Vértebras Lombares/cirurgia , Procedimentos Neurocirúrgicos/métodos , Escoliose/cirurgia , Cirurgia Assistida por Computador/métodos , Vértebras Torácicas/cirurgia , Procedimentos Cirúrgicos Ultrassônicos/métodos , Adolescente , Perda Sanguínea Cirúrgica , Criança , Feminino , Humanos , Masculino , Duração da Cirurgia , Parafusos Pediculares , Escoliose/congênito
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