Liminality in the occupational identity of mental health peer support workers: A qualitative study

Peer support is increasingly provided as a component of mental health care, where people in recovery from mental health problems use their lived experiences to provide support to those experiencing similar difficulties. In the present study, we explored the evolution of peer support workers’ (PSW) occupational identities. A qualitative study was undertaken alongside a pilot randomized, controlled trial of peer support for service users discharged from a mental hospital in London, UK. Two focus groups were conducted with eight PSW. Semistructured interviews were conducted with 13 service users receiving peer support and on two occasions with a peer support coordinator. The data were analysed using theoretical thematic analysis, focussing on occupational identity formation. We discuss how the occupational identity of PSW evolved through the interplay between their lived experience, their training, and their engagement in the practice environment in such a way as to construct a liminal identity, with positive and negative outcomes. While the difficulties associated with the liminality of PSW could be eased through the formalization and professionalization of the PSW role, there are concerns that this could lead to an undermining of the value of PSW in providing a service by peers for peers that is separate from formal mental health care and relationships. Skilled support is essential in helping PSW negotiate the potential stressors and difficulties of a liminal PSW identity.     

Correct allometric analysis is always helpful for scaling flow‐mediated dilation in research and individual patient contexts

McLay et al. (Clin Physiol Funct Imaging (2017); DOI: 10.1111/cpf.12465 ) recently examined whether the allometric scaling of flow‐mediated dilation influenced the mean difference between samples of young and older adults compared with the traditional percentage change approach. They also explored whether a new scaling calculation improved the ability to obtain individually scaled flow‐mediated dilation. In our response to their study, we can demonstrate that McLay et al. (Clin Physiol Funct Imaging, 2017) have (i) managed to formulate a new scaling index which does nothing to remove the dependency of that index on baseline diameter and (ii) suggested, incorrectly, that the original allometric approach cannot be used to derive individually‐adjusted values of flow‐mediated dilation, which can be interpreted in a similar way to a percentage change.     

Radio Frequency Ablation and Pulsed Radiofrequency for Treating Peripheral Neuralgias

Purpose of Review

Peripheral nerve pain is common among patients with typical management including the use of pain medications, neuropathic agents, steroid injections, and nerve blocks. Additionally, the use of pulsed radiofrequency (PRF) and radiofrequency ablation (RFA) can be used in the management of chronic peripheral nerve pain. Previous studies investigating the effectiveness of RFA and PRF, typically case reports, have demonstrated that peripheral nerve RFA and PRF have the potential to provide relief of chronic pain for long duration. Our study aimed at testing efficacy of RFA/PRF for treating peripheral neuralgia. This was a retrospective review. We identified 16 patients who received 17 RFAs/PRFs. Outcomes of interest collected included pain scores before and after procedures, percent improvement in pain after each procedure, and duration of improvement until the time of data collection. In addition, demographic data including age, sex, and nerves involved were collected.

Recent Findings

Eleven patients (12 RFAs/PRFs) (80%) reported improvement after their procedure. Pain scores improved significantly from 6.3?±?2.3 before each procedure to 3.6?±?2.7 after each procedure (p?=?0.003). Eleven patients (12 RFAs/PRFs) reported an average improvement of 60.8%?±?35% after their procedure with an average duration of improvement of 128.8?±?106.8 days.

Summary

RFA and PRF can be used to treat chronic peripheral pain after conservative methods fail to do so. Large clinical trials are needed to confirm our finding.

     

Complex Regional Pain Syndrome,Current Concepts and Treatment Options

Purpose of Review

Complex regional pain syndrome (CRPS) refers to a chronic pain condition that is characterized by progressively worsening spontaneous regional pain without dermatomal distribution. The symptomatology includes pain out of proportion in time and severity to the inciting event. The purpose of this review is to present the most current information concerning epidemiology, diagnosis, pathophysiology, and therapy for CRPS.

Recent Findings

In recent years, discovery of pathophysiologic mechanisms of CRPS has led to significant strides in the understanding of the disease process.

Summary

Continued elucidation of the underlying pathophysiological mechanisms will allow for the development of more targeted and effective evidence-based therapy protocols. Further large clinical trials are needed to investigate mechanisms and treatment of the disorder.

     

Novel Interventional Nonopioid Therapies in Headache Management

Purpose of Review

Headaches encompass a broad-based category of a symptom of pain in the region of the head or neck. For those patients who unfortunately do not obtain relief from conservative treatment, interventional techniques have been developed and are continuing to be refined in an attempt to treat this subset of patients with the goal of return of daily activities. This investigation reviews various categories of headaches, their pathophysiology, and types of interventional treatments currently available.

Recent Findings

Injection of botulinum toxin has been shown to increase the number of headache free days for patients suffering from chronic tension-type headaches. Suboccipital steroid injection has been demonstrated as a successful treatment option for patients suffering from cluster headache. Occipital nerve stimulation (ONS) has been described as a treatment for all types of trigeminal autonomic cephalgias. Percutaneous ONS is a minimally invasive and reversible approach to manage occipital neuralgia performed utilizing subcutaneous electrodes placed superficial to the cervical muscular fascia in the suboccipital area. Radiofrequency lesioning is another commonly used treatment in the management of chronic pain syndromes of the head and neck. If a diagnostic sphenopalatine ganglion block successfully resolves the patient’s symptoms, neurolysis can be employed as a more permanent solution.

Summary

Although many patients who suffer from headaches can be treated with conservative, less-invasive treatments, there still remains at present an ever-increasing need for those patients who are refractory to conservative measures and thus require interventional treatments. These procedures are continually evolving to become safer, more precise, and more readily available for clinicians to provide to their patients.

     

Stepped‐wedge cluster randomised controlled trials: a generic framework including parallel and multiple‐level designs

Stepped‐wedge cluster randomised trials (SW‐CRTs) are being used with increasing frequency in health service evaluation. Conventionally, these studies are cross‐sectional in design with equally spaced steps, with an equal number of clusters randomised at each step and data collected at each and every step. Here we introduce several variations on this design and consider implications for power. One modification we consider is the incomplete cross‐sectional SW‐CRT, where the number of clusters varies at each step or where at some steps, for example, implementation or transition periods, data are not collected. We show that the parallel CRT with staggered but balanced randomisation can be considered a special case of the incomplete SW‐CRT. As too can the parallel CRT with baseline measures. And we extend these designs to allow for multiple layers of clustering, for example, wards within a hospital. Building on results for complete designs, power and detectable difference are derived using a Wald test and obtaining the variance–covariance matrix of the treatment effect assuming a generalised linear mixed model. These variations are illustrated by several real examples. We recommend that whilst the impact of transition periods on power is likely to be small, where they are a feature of the design they should be incorporated. We also show examples in which the power of a SW‐CRT increases as the intra‐cluster correlation (ICC) increases and demonstrate that the impact of the ICC is likely to be smaller in a SW‐CRT compared with a parallel CRT, especially where there are multiple levels of clustering. Finally, through this unified framework, the efficiency of the SW‐CRT and the parallel CRT can be compared. © 2014 The Authors. Statistics in Medicine Published by John Wiley & Sons Ltd.