Use of acupuncture for chronic pain: optimizing clinical practice

Increasingly, individuals are turning to complementary therapies to reduce or cope with chronic pain. Acupuncture, one of the oldest complementary therapies, originated from China more than 2500 years ago. It has steadily gained popularity in the United States over the last few decades as a modality for pain relief among both practitioners and patients. A 1997 National Institutes of Health consensus conference concluded that acupuncture needling releases endorphins and other neurotransmitters in the brain and should be considered as an appropriate pain treatment option. This article will provide an overview about acupuncture principles, discuss current clinical evidence, and identify acupuncture resources to optimize practice for chronic pain management.     

Perspectives on research evidence and clinical practice: a survey of Australian physiotherapists

Background and Purpose . Physiotherapists' use of research evidence with clinical decision‐making has interested researchers world‐wide since 1980; however, little is known about such practices in Australia. The present survey sought information on Australian physiotherapists' perceptions of the importance of research, and barriers to uptake of evidence in clinical practice, when compared with an international cohort from 2001. Method . An Australian‐relevant version of an English (UK) National Health Service (NHS) survey instrument was used to canvass 453 physiotherapists, randomly selected from the South Australian Physiotherapy Registration Board 2004–2005 records. The first survey was mailed in August 2005, a reminder was sent two weeks later to non‐responders and a follow‐up survey was sent in April 2006 to non‐responders whose addresses had changed since 2005. Results . There was a 51% response rate. Of the non‐responders, 12% were not contactable at their listed address, highlighting the mobility of Australian physiotherapists. Most respondents had undertaken research as students (59.5%) or as students and clinicians (11.5%). Of these, 37.1% were encouraged to embark on more research, and 20.5% were discouraged. The significant predictors of positive perceived importance of research were: previous research experience; being positive about undertaking further research; working in hospitals and holding a postgraduate degree. Clinicians working privately were significantly less likely than managers to be positive about research importance. The only significant predictor for not perceiving barriers to uptake of evidence was being positive about undertaking future research. Conclusions . The study identified constraints on uptake of evidence into practice that were related to accessing, reading and interpreting published research, and implementing findings. Found consistently across employment categories were barriers relating to lack of time, uncertainty about what the research reported, scepticism about the value of research and being isolated from peer support and literature sources. The responses indicated a positive shift towards evidence uptake since the 2001 NHS survey, suggesting an influence of increased exposure to information on evidence‐based practice. A greater focus on research whilst training, the application of educational strategies for empowerment, better knowledge transfer and upskilling within the workplace, and ensuring dedicated time and organizational support for research activities are indicated. Copyright © 2007 John Wiley & Sons, Ltd.     

Phantom pain: a lesson in the necessity for careful clinical research on chronic pain problems

Recent findings suggest that major misunderstandings concerning the prevalence, characteristics, etiology, and treatment effectiveness of phantom pain have led to the widespread mismanagement of amputees throughout the history of modern medicine. For years it has been believed that phantom pain is relatively rare, is of unknown etiology, and probably has a psychological basis. Research results over the last few years, however, suggest that phantom pain is widely prevalent among individuals with amputations and most likely has a physiological basis. Although many different treatments have been introduced recently, few, if any, have yet been documented as effective due to lack of rigorous follow-up studies. Future progress in clinical treatment and increased scientific understanding of phantom pain will require an examination of some of the factors that have led to past confusion regarding scientific research on and clinical treatment of phantom pain.     

Development and administration of a survey instrument for cross-cultural research

The purpose of this article is to provide a brief review of guidelines for development of culturally appropriate measures of phenomena. The principles are illustrated by citing an example of their use in developing a survey instrument to be used with a rural Mexican American and Euro American population. Discussion focuses on practical issues of implementing the approaches suggested in the literature and adds to the literature about issues in formatting and administration of survey instruments used in cross-cultural research. © 1993 John Wiley & Sons, Inc.     

Treatment of low back pain: monitoring clinical practice through audit

Objectives

Back pain is one of the most common causes of disability in the UK. Management guidelines for the treatment of acute back pain have been published. Auditing patients’ physiotherapy treatment records is one way of monitoring standards of care. Standards were developed using published evidence-based treatment, self-management guidelines and local standards within a physiotherapy outpatient department.

Design

Physiotherapy treatment notes for patients referred with low back pain were audited in 1996 (Audit 1). The audit was repeated in 2001 (Audit 2) after additional standards were implemented following the results of Audit 1.

Setting

Physiotherapy Outpatient Department, Addenbrooke's NHS Trust Hospital, Cambridge, UK.

Results

In Audit 1, 66% and 88% of patient records indicated that they were compliant with the standards for acute and chronic back pain, respectively. Sixty-four percent of patients were advised to keep active, 96% showed evidence of diagnostic triage, 65% showed evidence of mobilisation, none were recommended bed rest (100% compliance), and there was no evidence of manipulation. In Audit 2, 57% and 51% of patient records indicated that they were compliant with the standards for acute and chronic back pain, respectively. Thirty percent were considered to be yellow flags, 59% showed evidence of mobilisation, 100% showed evidence of diagnostic triage and did not recommend bed rest, 60% were referred for rehabilitation, and there was no evidence of manipulation. Changes instigated included new appointment and referral systems and new topics for staff education.

Conclusion

Auditing physiotherapy treatment notes of patients with low back pain has been shown to be useful in monitoring areas of good practice and in identifying practice in need of development. Clinical audit should be seen as a quality improvement process that aims to optimise patient care.     

Intraspinal opioid therapy for chronic nonmalignant pain: Current practice and clinical guidelines

The multidimensional nature of chronic nonmalignant pain lends itself to numerous treatment options, which vary in cost and invasiveness. Based on the principle that use invasive and less costly interventions for pain treatment should be attempted first, a continuum of interventions for chronic pain states is presented. Although intraspinal opioid therapy is a relatively invasive and costly modality for pain treatment, it has a rational place in the treatment continuum for some chronic nonmalignant pain patients. A through review of the literature, supplemented by clinical experience, provides a foundation for the development of management guidelines.     

AHCPR clinical practice guideline on surgical pain management: adoption and outcomes

Pain management practices and short-term patient outcomes in nine acute care hospitals in Milwaukee, Wisconsin, were studied at two points in time. One-and-a-half years after the Agency for Health Care Policy and Research's (AHCPR) Clinical Practice Guideline on Acute Pain Management was published, data from 330 adult surgical patients were collected (Time I). These data were contrasted with data from 373 adult surgical patients collected 2 years later (Time II). There were significant increases in the percentage of patients who reported being taught how to report pain using a pain rating scale and about setting a pain goal preoperatively; in the percentage of patient hospital records with at least one documented numeric pain rating; and in the percentage of patients who received analgesics by intravenous administration. However, pain management practices continued to differ from recommendations in the AHCPR guideline. No significant improvement was noted in the short-term outcomes of patient-rated pain or patient satisfaction with pain management. Availability of well-published guidelines alone may be insufficient to ensure comprehensive adoption of guidelines that are multidimensional in nature and to obtain improvements in patient outcome.     

Evidence-based practice: a framework for clinical practice and research design

The evidence-based practice (EBP) framework emerged in the early 1970s as a means of improving clinical practice. This shift towards EBP allowed health professionals to move from a culture of delivering care based on tradition, intuition and authority, to a situation where decisions were guided and justified by the best available evidence. Despite the many advantages of EBP, many practitioners remain cautious about embracing the model. Part of this opposition is due to a misunderstanding of EBP, which this paper aims to address.     

The actometer: an evaluation of instrument applicability for chronic pain patients

Three experiments were conducted to determine the reliability and validity of an activity measurement device, the actometer, as an index of ambulation for chronic pain patients. In experiment I, correlations between yoked actometers during ambulation showed the instrument to be internally reliable. In experiment II, actometer readings covaried very strongly with distance, showing the device to be valid during single trial assessment. However, experiment III found the device to show poor reliability over time (i.e., substantial measurement variability for the identical distance on 3 separate days). The results suggest that, for the chronic pain population, the actometer may not be a useful instrument for reliably assessing changes in walking activity over time.     

Granisetron (Kytril): a survey of use in clinical practice in Switzerland

Data on the use of intravenous granisetron (Kytril) were collected during a surveillance exercise amongst Swiss oncologists. The data were analysed to ascertain how granisetron was used, and to document the incidence of adverse experiences in a clinical setting. Forty-nine oncologists at 40 Swiss centres were surveyed for their use of granisetron for the prevention and treatment of chemotherapy-induced nausea and vomiting. All were advised to follow the Swiss prescribing instructions for granisetron. They were invited to return data on patient demography, chemotherapy duration, granisetron dosing and adverse experiences. From 285 patients it was deduced that the mean daily dose of granisetron was 1.3 ampoules (3.9 mg) and the median daily dose was 1 ampoule (3 mg). The average number of doses of granisetron per patient per session was 3.8. There were 44 reports of adverse experiences by 34 patients, the most common report being headache. The survey confirmed that the large majority of patients undergoing chemotherapy required only a single dose of granisetron per day, and that the adverse experience profile was good.The data in this article were reported in part as a poster presentation to the 7th ECCO meeting Jerusalem, 1993     

Incorporating outcomes research into clinical practice: the four-step approach

Outcomes research is designed to develop new and generalizable knowledge about care delivery, interventions, and patient outcomes. Advanced practice nurses are asked not only to participate in outcomes research but also to develop and maintain outcomes research projects and databases and to demonstrate the effectiveness of their own care practices through outcomes research. A four-step approach is described as an easy way in which to help advanced practice nurses engage in outcomes research at any site and with any patient population. The four steps are: Step I: identify and describe current practice in nursing-medical care and its outcome(s); Step II: data collection; Step III: data analysis; and Step IV: praxis: putting the research into practice. Participating in outcomes research will allow advanced practice nurses to improve healthcare services and to secure the role of advanced practice nurses in the changing healthcare arena.     

Identifying important outcome domains for chronic pain clinical trials: an IMMPACT survey of people with pain

This two-phase study was conducted to identify relevant domains of patient-reported outcomes from the perspective of people who experience chronic pain. In Phase 1, focus groups were conducted to generate a pool of patient outcome-related domains and their components. The results of the focus groups identified 19 aspects of their lives that were significantly impacted by the presence of their symptoms and for which improvements were important criteria they would use in evaluating the effectiveness of any treatment. Phase 2 was conducted to examine the importance and relevance of domains identified from a much larger and diverse sample of people with chronic pain. A survey was developed and posted on the American Chronic Pain Association website. Participants were asked to rate the importance of each item or domain identified by the focus groups on a scale of 0 to10 (i.e., 0="not at all important" and 10="extremely important"). The survey was completed by 959 individuals. The results indicate that all 19 aspects of daily life derived from the focus groups were considered important with a majority of respondents indicating a score of 8 or greater. In addition to pain reduction, the most important aspects were enjoyment of life, emotional well-being, fatigue, weakness, and sleep-related problems. Chronic pain clearly impacts health-related quality of life. The results of the two phases of the study indicate that people with chronic pain consider functioning and well-being as important areas affected by the presence of symptoms and as appropriate targets of treatment. These multiple outcomes should be considered when evaluating the efficacy and effectiveness of chronic pain treatments.