Patient decision-making regarding entry into psychotherapy to treat depression

Many individuals with depression want treatment, and most believe that psychotherapy will treat symptoms of depression, yet many do not initiate care beyond their primary care physicians. This becomes critical given the low to moderate adherence rate to antidepressant medications among depressed patients treated in primary care. Many are left untreated or under-treated. The purpose of this study was to investigate whether attitudes toward psychotherapy in a population of primary care patients newly diagnosed with depression influenced the likelihood that they initiated psychotherapy. Participants were asked to complete two attitudinal questionnaires and respond to a three-month follow-up phone call regarding therapy initiation. Reported attitudes toward psychotherapy were positive. Many perceived therapy as both effective and preferred over medications. Despite positive attitudes, the rate of initiation into psychotherapy remained alarmingly low.     

Body perception disturbance: a contribution to pain in complex regional pain syndrome (CRPS)

In spite of pain in the CRPS limb, clinical observations show patients pay little attention to, and fail to care for, their affected limb as if it were not part of their body. Literature describes this phenomenon in terms of neurological neglect-like symptoms. This qualitative study sought to explore the nature of the phenomenon with a view to providing insights into central mechanisms and the relationship with pain. Twenty-seven participants who met the IASP CRPS classification were interviewed using qualitative methods to explore feelings and perceptions about their affected body parts. These semi-structured interviews were analysed utilising principles of grounded theory. Participants revealed bizarre perceptions about a part of their body and expressed a desperate desire to amputate this part despite the prospect of further pain and functional loss. A mismatch was experienced between the sensation of the limb and how it looked. Anatomical parts of the CRPS limb were erased in mental representations of the affected area. Pain generated a raised consciousness of the limb yet there was a lack of awareness as to its position. These feelings were about the CRPS limb only as the remaining unaffected body was felt to be normal. Findings suggest that there is a complex interaction between pain, disturbances in body perception and central remapping. Clinically, findings support the use of treatments that target cortical areas, which may reduce body perception disturbance and pain. We propose that body perception disturbance is a more appropriate term than 'neglect-like' symptoms to describe this phenomenon.     

Analgesic action of gabapentin on chronic pain in the masticatory muscles: a randomized controlled trial

Chronic masticatory myalgia (CMM) can be defined as constant pain in the masticatory muscles for more than 6 months and is influenced by the central nervous system. The antiepileptic agent gabapentin acts centrally and is used for managing different types of chronic pain conditions. The objective of this study was to evaluate the analgesic action of gabapentin on CMM. In this 12-week randomized controlled clinical trial 50 patients were randomly allocated into two study groups: 25 received gabapentin and 25 received placebo. The outcome measures utilized were pain reported on a VAS (VAS-pain), Palpation Index (PI) and impact of CMM on daily functioning reported on a VAS (VAS-function). Thirty-six patients completed the study. Gabapentin showed to be clinically and statistically superior to placebo in reducing pain reported by patients (gabapentin=51.04%; placebo=24.30%; P=0.037), masticatory muscle hyperalgesia (gabapentin=67.03%; placebo=14.37%; P=0.001) and impact of CMM on daily functioning (gabapentin=57.70%; placebo=16.92%; P=0.022). It can be concluded from this study that gabapentin is effective for the management of CMM.     

Establishing a super-link system: spinal cord injury rehabilitation nursing

AIM: This paper reports a study to identify the needs of clients with spinal cord injury and their family/carers during rehabilitation, and the strategies used by rehabilitation nurses to meet those needs. BACKGROUND: In Taiwan, spinal cord injury is a major problem with financial implications for the state and major bio-psycho-social and spiritual implications for the individual. Rehabilitation nurses do not have an appropriate nursing theory to guide their care. METHODS: Using a grounded theory approach, data were collected from October 2002 to March 2003 in a rehabilitation hospital in Taiwan by means of interviews, participant observations and documentary resources; analysis was an interrelated process. A total of 39 interviews was carried out with 31 individuals, including eight rehabilitation nurses, one nurse supervisor, seven clients with tetraplegia, eight with paraplegia and seven family/carers. There were 18 participant observations. Data were analysed using a multi-step analytic procedure, based on the works of Glaser, Charmaz, and Strauss and Corbin. FINDINGS: The core category, 'establishing a super-link system', explained the complex structure of interactions observed during the investigation and the importance of developing a middle-range theory entitled the 'Super-Link System Theory'. This theory includes the following four links: 'linking to client', 'linking to family/carer', 'linking to interdisciplinary rehabilitation team' and 'linking to community'. CONCLUSION: This Super-Link System Theory will help rehabilitation nurses to organize their thinking about spinal cord injury rehabilitation nursing, to transfer their thinking into practice by making links effective, and to promote their professional position in the interdisciplinary rehabilitation team.     

Using the Quality-Caring Model to organize patient care delivery

The organization of patient care in many acute care institutions lacks a foundation in nursing theory, yet preliminary evidence of the value of professional nursing care is increasing. The process and preliminary benefits of organizing patient care according to a professional practice model are presented using a collaborative partnership between an acute care organization and a school of nursing. A pilot implementation plan with formative and summative evaluation provided preliminary evidence used in project expansion.     

School dental screening does not increase dental attendance rates or reduce disease levels

DESIGN: This was a cluster randomised controlled trial, in which the unit of randomisation was the school. INTERVENTION: Three models of screening were tested against a control. A 'new' model of school dental screening incorporated a consensus view, from clinicians in the northwest of England, on a set of clinical criteria that would prompt a referral following a screening examination. A 'traditional' model involved the delivery of the existing school dental screening programme according to the principle that a child is referred if, in the opinion of the screening dentist, dental care is required. The third intervention tested was a dental information leaflet, distributed via the schools, which encouraged parents to examine their child's mouth and to take their child to a dentist if any problems were noted. Children a ttending the control schools received no intervention during the study period. OUTCOME MEASURE: The main outcome measures were prevalence of teeth with active caries and mean number of teeth with active caries in the permanent or primary dentition. Secondary outcome measures were prevalence of oral sepsis, gross plaque or calculus, and dental trauma to incisor teeth. RESULTS: Seventeen thousand and ninety-eight children in 169 clusters (schools) were eligible for inclusion in the study. One school was withdrawn from the study because of failure to agree to follow the trial protocol. Of the total, 15 004 children were available for baseline examination in 168 schools and 13 570 children received a baseline and outcome examination, representing 80.5% of the eligible population. After adjustment for clustering of children in schools, there was no significant difference in the reduction from baseline in untreated caries between the study groups in either the primary or permanent dentition. Similarly there were no significant differences across the four arms of the study in the secondary outcome measures of prevalence of sepsis, presence of gross plaque or calculus, and trauma to the permanent incisor teeth. In the traditional arms, 42% of children attended a dentist during the study period, with 41% in the new-model arm, 37% in the information-leaflet arm and 38% in the control arm. Although more children in the traditional and new-model arms of the study attended a dental appointment these differences were not statistically significant.CONCLUSIONS: School dental screening delivered according to three different models was not effective at reducing levels of active caries and increasing dental attendance in the population under study.     

Clinical prediction rules can be derived and validated for injured Australian workers with persistent musculoskeletal pain: an observational study

QUESTIONS: Can clinical prediction rules be derived for injured Australian workers with persistent musculoskeletal pain? Are they valid? DESIGN: Longitudinal observational study. PARTICIPANTS: 847 injured workers with persistent musculoskeletal pain undergoing rehabilitation. OUTCOME MEASURES: At baseline, 12 putative predictors were measured. At 9 weeks, short-term outcomes such as pain (visual analogue scale), activity limitation (Functional Rating Index) and work upgrade (increase in work hours or duties) were measured. At 6 months, long-term work status (working or not working) was measured. RESULTS: Data were obtained from 85% of the participants who were followed up at both 9 weeks (720 of 847) and 6 months (247 of 290). Predictors of outcome included high baseline pain and activity limitation, long duration of previous intervention, not working, non-English speaking background, and the area of pain. Accuracy was highest for clinical prediction rules predicting pain and level of activity limitation at 9 weeks (R2 = 0.67 and 0.69 respectively) and work status at 6 months (LR- = 0.24). CONCLUSION: Accurate clinical prediction rules have been derived and validated for injured workers with persistent musculoskeletal pain, predicting activity limitation, pain, and work outcomes following exercise-based rehabilitation. Further research to validate these prediction rules in other populations and to assess the effectiveness of tailoring intervention based on the estimated prognosis would be valuable.     

Defining spirituality and giving meaning to occupation: the perspective of community-dwelling older adults with autonomy loss

BACKGROUND: In the Canadian Model of Occupational Performance, meaningful occupation involves interaction between spirituality and environment. However little research exists on the process of giving meaning to occupation. PURPOSE: This study explored both meaningful occupation and the definition of spirituality from the perspective of community-dwelling older adults with autonomy loss. METHOD: Using a qualitative approach, grounded theory method of Glaser and Strauss (1967), eight cognitively intact persons were interviewed individually. RESULTS: The process of giving meaning to occupation involves an intrinsic link between identity and meaningful occupation, with identity being central to the person. Following autonomy loss, a process of adjusting identity, involving social, psychological and spiritual aspects, occurs over time. Spirituality is defined in terms of its close links to religion and belief in a benevolent greater power. IMPLICATIONS OF RESEARCH: This study contributes to the discussion of the concepts of spirituality, identity and meaning in occupational therapy.