Risultati per: Low Back Pain: raccomandazioni

Introduction
Rotator cuff-related shoulder pain is the most common diagnosis of shoulder pain, which ranks as the third most common musculoskeletal disorder. The first-line treatment for patients with rotator cuff-related shoulder pain is physiotherapy, and joint mobilisation is widely used in conjunction with other modalities. The type and dosage of joint mobilisations could influence treatment outcomes for patients with rotator cuff-related shoulder pain, although research evidence is inconclusive.

Objectives
To (1) systematically search, identify and map the reported type and dosage of joint mobilisations used in previous studies for the management of patients with rotator cuff-related shoulder pain; and (2) summarise the rationale for adopting a specific joint mobilisation dosage.

Methods and analysis
We will follow the methodological framework outlined by Arksey and O’Malley and report the results as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guideline. Two authors will independently screen and extract data from the six databases: PubMed, Scopus, Web of Science, CINAHL, Cochrane Library and SPORTDiscus, with publication date from their inceptions to 25 August 2021. A third author will be consulted if the two authors disagree about the inclusion of any study in the review. We will summarise the results using descriptive statistics and qualitative thematic analysis.

Ethics and dissemination
Ethical approval is not required for this protocol. Mapping and summarising the reported type and dosage of joint mobilisations for patients with rotator cuff-related shoulder pain from previous studies will provide a foundation for further optimal selection of type and dosage of joint mobilisations for treating patients with rotator cuff-related shoulder pain. The review is part of an ongoing research that focuses on joint mobilisation for patients with rotator cuff-related shoulder pain. The results will be disseminated through presentations at academic conferences and a peer-reviewed publication.

Introduction
Many people with HIV report both distress and pain. The relationship between distress and pain is bidirectional, but the mechanisms by which distress exacerbates pain are unclear. The inflammatory response to challenge (inflammatory reactivity, IR) may be a partial mediator, given that neuroimmune interactions provide a substrate for IR to also influence neurological reactivity and, thus, pain-related neural signalling. This prospective, observational, case–control study will characterise the relationships between distress, IR, pain-related signalling as captured by induced secondary hyperalgesia (SH), and pain, in people with HIV who report persistent pain (PP) (cases) or no pain (controls).

Methods and analysis
One hundred people with suppressed HIV, reporting either PP or no pain, will be assessed two or four times over 6 months. The primary outcomes are distress (Hopkins 25-item symptom checklist), IR (multiplex assay after LPS challenge), and PP (Brief Pain Inventory), assessed at the baseline timepoint, although each will also be assessed at follow-up time points. Induced SH will be assessed in a subsample of 60 participants (baseline timepoint only). To test the hypothesis that IR partly mediates the relationship between distress and pain, mediation analysis will use the baseline data from the PP group to estimate direct and indirect contributions of distress and IR to pain. To test the hypothesis that IR is positively associated with SH, data from the subsample will be analysed with generalised mixed effects models to estimate the association between IR and group membership, with SH as the dependent variable.

Ethics and dissemination
Information obtained from this study will be published in peer-reviewed journals and presented at scientific meetings. The study has been approved by the Human Research Ethics Committee of the University of Cape Town (approval number: 764/2019) and the City of Cape Town (ref: 24699).

Trial registration number
NCT04757987.

Question: A 44-year-old Vietnamese woman with a past medical history of hypertension presented with a 3-day history of diffuse intermittent abdominal pain associated with nausea, nonbloody nonbilious emesis, and brown loose stools. She noted worsening multiarticular joint pain including her fingers, wrists, shoulders, hips, and knees, associated with morning stiffness. She recalled a similar episode of abdominal pain with concurrent joint symptoms 2 months ago, which spontaneously resolved.

Background
Behavioural activation (BA) is an effective treatment for depression; however, it is unclear if it can be used to manage pain.

Objectives
To conduct a scoping review of primary research that reported using BA to support people living with chronic pain to understand how BA had been used in relation to pain. In addition, we wanted to understand whether there were any reported changes in that pain, and how and who delivered BA.

Eligibility criteria
Primary research published in English.

Sources of evidence
We searched seven databases MEDLINE, Ovid Embase, Ovid Emcare, PsycINFO, CINAHL, Scopus and Web of Science, for primary research. No initial date limit was used with the date the searches were conducted used as the end date limit (1 July 2021).

Charting methods
A customised data extraction table was developed, piloted and used.

Results
551 papers were screened for inclusion, with 15 papers included in our review. Studies were conducted in North America and in Canada. These included three case studies, nine uncontrolled trials and three randomised controlled trials. Only two studies reported pain as the primary outcome. BA was applied across a range of pain related conditions. The dose of BA ranged from 3 to 16 sessions. Duration of treatment was 3 weeks to 12 months. Most studies reported reductions in pain following exposure to BA.

Conclusion
BA has the potential to reduce pain. Caution needs to be exercised in the interpretation of these findings as a high risk of bias was observed in most studies. High-quality research is required to test if BA is an effective intervention for chronic pain.

Question: A 78-year-old woman presented to the emergency department with 2 weeks of right upper quadrant abdominal pain, fatigue, and weight loss. She described a loss of appetite, but denied fever, chills, or diarrhea. There was no history of prior biliary disease, hepatitis, recent travel, drug use, or new sexual partners. Her history was notable for psoriatic arthritis, which was well-controlled on ustekinumab. The physical examination was remarkable for tenderness in the right upper quadrant without other stigmata of liver disease.

BackgroundPatient and public involvement is an integral component of clinical research. A YPAG is group of young people with active involvement in the design and conduct of clinical research aimed at CYP.1 2 Active collaboration with a YPAG can be mutually beneficial and can have a positive impact on study design and conduct.2 3 We report on the involvement of young people, their influence on study design and the perceived benefits to members.MethodA UK secondary school was approached and ten 16–17 year old students agreed to form a YPAG. Three 1-hour sessions were planned involving arts-based activities to explore key challenges, predetermined iteratively by the research team. Activities involved group work to explore and propose solutions for effective CYP recruitment and data collection, produce a study logo and review the plain English summary.ResultsYPAG members produced insightful arts-based posters containing important ideas and concepts that were incorporated into the study design. A study logo was created, diaries and electronic communication methods to collect data were added and a variety of age-based leaflets were added to the recruitment strategy. Members reported several benefits from the sessions, including enhanced creative and problem-solving skills and members enjoyed the teamwork and collaborative approach.ConclusionYPAG involvement resulted in meaningful improvements to research design and members gained new knowledge, transferrable skills and improved confidence. This experience should help inform YPAG involvement in future research.ReferencesNational Institute for Health Research (2021) NIHR resource for public involvement – Involving children and young people as advisors in research. Available at: https://www.learningforinvolvement.org.uk/?opportunity=nihr-involving-children-and-young-people-as-advisors-in-research Accessed 06-Dec-2021Rouncefield-Swales A, Harris J, Carter B, Bray L, Bewley T, et al. (2021) Children and young people’s contributions to public involvement and engagement activities in health-related research: A scoping review. PLOS ONE 16(6): e0252774. https://doi.org/10.1371/journal.pone.0252774Abrehart N, Frost K, the Young Persons Advisory Group. et al. (2021) ‘A little (PPI) MAGIC can take you a long way’ : involving children and young people in research from inception of a novel medical device to multi-centre clinical trial Roald Dahl, James and the Giant Peach (1961). Res Involv Engagem 7, 2 https://doi.org/10.1186/s40900-020-00243-0.Conflict of interestGAW received funding to conduct this project through a post-doctoral bridging fellowship. HT, TB, EM and RT received financial compensation, in line with NIHR/INVOLVE guidelines, for their involvement in the YPAG group.FundingThis project formed part of a post-doctoral bridging fellowship supported by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands (ARC EM) and Health Education England. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

BackgroundDistraction therapies are widely used to manage pain and anxiety in paediatric emergency departments (ED). Paediatric patients also comprise up to 13% of some ambulance services workloads1 yet only a single study exists outlining the ad-hoc use of paramedic-initiated distraction therapy.2 Building rapport with frightened, unwell children is challenging for paramedics, but is essential to facilitate rapid assessment and care.1,3.This review aims to identify effective ED distraction techniques potentially suitable for use in paediatric patients in the prehospital setting.MethodDatabases and grey literature sources including Ovid Medline, EMBASE and CINAHL and Google Scholar were searched from their beginning to October 2021. English language interventional or observational studies were included if they reported on distraction techniques suitable for use in the prehospital setting, paediatric ED presentations, and pain and/or anxiety.ResultsOf the 4,054 records screened, 27 met the eligibility criteria. Twenty randomised trials and seven interventional studies involved children aged three months to 18 years. Distraction techniques were digital, non-digital and environmental adaptations and included virtual-reality, cartoons, music, vibration devices, bubble-blowing and ambient lighting. Ten studies reported significant reductions in self-reported pain and seven for self-reported anxiety. Some reported reduced pharmacological administration and improved patient cooperation, and parent and/or healthcare provider satisfaction when using distraction. Studies were highly heterogeneous with 17 distractors and 21 pain and/or anxiety measurement tools used.ConclusionA range of effective distraction techniques exist in paediatric EDs that may be suitable for the prehospital setting to manage pain and/or anxiety and improve patient outcomes.ReferencesFowler J, Beovich B, Williams B. Improving paramedic confidence with paediatric patients: a scoping review. Australasian Journal of Paramedicine 2017;15(1).Preston C and Bray L. Developing understanding and awareness of children’s distress, distraction techniques and holding. Journal of Paramedic Practice 2015;7(3):122–130.Cushman JT, Fairbanks RJ, O’Gara KG, et al. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care 2010;14:477–84.Conflict of interestNone.FundingAU$4000 in funding has been provided by the Australia and New Zealand College of Paramedicine, and AU$11,000 in funding was provided through a Monash University Advancing Womens Research Success Grant for this program of research. Dr Eastwood, Dr Howell and Professor Cameron are supported by the National Health and Medical Research Council (NHMRC) Prehospital Emergency Care Centre for Research Excellence (PEC-ANZ; #1116453).

BackgroundAdequate management of pain in children if often a neglected aspect, usually underevaluated and under-treated. This study is a continuous review to see if pharmacological methods provided during the prehospital care of pediatric trauma patients is proper.MethodRetrospective study of clinical records of children up to 18 year of age, assisted between 2017 and 2018. Mild pathologies excluded. Epidemiological variables: age, gender, diagnosis, pediatric trauma score(PTS), analgesia, numeric rate scale(NRS), drugs administered. Quantitative variables: central and dispersión measures. Inferential statistical análisis: relationship quantitative variables, Student’s t test and categorical variables, Chi square. 95% confidence intervals, p

BackgroundPrevious studies in the prehospital setting have reported wide variation in the incidence and severity of pain, and that documentation of pain scores is poor. The aim of our study was to investigate and describe the incidence and severity of patient-reported pain that is recorded by pre-hospital emergency care patients in Ireland.MethodWe used data from our electronic patient care record (ePCR) repository to perform this retrospective cohort study of all emergency care episodes recorded by National Ambulance Service practitioners during 2020. Descriptive analysis of patient and care characteristics and regression analyses for the outcomes pain recorded and severity of pain were performed.ResultsOf the 212,401 patient care episodes included, 138,195 (65%) included a pain score (75,445 = no pain; 18,378 = mild pain; 21,451 = moderate pain; 22,921 = severe pain). The likelihood of pain being recorded was most strongly associated with the Glasgow Coma Score, working diagnosis, call location, and patient age. The variables showing strongest association with pain severity were transport outcome, working diagnosis, and patient age. Sensitivity analysis confirmed that all regression models performed better than chance, but that all models were relatively weak at predicting the outcomes.ConclusionUsing a large real-world dataset, we have demonstrated patient and care episode characteristics that are associated with recording and severity of self-reported pain. We have identified actionable improvements that will strengthen the prediction accuracy of routinely collected data and ultimately improve pain management for our patients.Conflict of interestNone to declare.FundingNo specific funding received or sought for this study.

Stroke, Ahead of Print. BACKGROUND:Lp(a) (lipoprotein(a)) contributes to cardiovascular disease mainly through proatherogenic and proinflammatory effects. Here, we aimed to evaluate whether a residual stroke risk of Lp(a) would remain when the LDL-C (low-density lipoprotein cholesterol) and inflammatory levels are maintained low.METHODS:This prospective cohort study included 9899 patients with ischemic stroke or transient ischemic attack from the Third China National Stroke Registry who had measurements of plasma Lp(a) and were followed up for 1 year. Cutoffs were set at the 50 mg/dL for Lp(a). LDL-C was corrected for Lp(a)-derived cholesterol (LDL-Cc [LDL-C corrected]) and cutoffs were set at 55 and 70 mg/dL.The threshold values of IL-6 (interleukin 6) and hsCRP (high-sensitive C-reactive protein) were the median 2.65 ng/L and 2 mg/L. Multivariable-adjusted hazard ratio (HR) were calculated using Cox regression models for each category to investigate the associations of Lp(a) with stroke recurrence within 1 year.RESULTS:Among all patients, those with Lp(a) ≥50 mg/dL were at higher stroke recurrence risk than those with Lp(a)

Stroke, Volume 53, Issue Suppl_1, Page AWMP107-AWMP107, February 1, 2022. Introduction:Genetic reference panels and imputation approaches have improved greatly in the last 10 years. The development of the TOPMed reference plane has led to enhanced imputation quality and quantity of single nucleotide polymorphisms (SNPs) due to greater sample diversity among various population ancestries. We revisited our prior GWAS of recurrent stroke by utilizing the TOPMed imputation server.Methods:This GWAS used a Cox proportional hazards model of time to recurrent stroke with the Vitamin Intervention for Stroke Prevention clinical trial cohort. There were 2,100 genotyped patients (64% male) in total with an average age of 67.2 (±10.8) years and ancestry distribution of 1,725 (82%) European, 258 (12%) African, and 117 (6%) Other or Mixed ancestry. Genotyped samples underwent a strict quality control process. We utilized TOPMed for imputation which totaled 10,467,887 biallelic SNPs which was 14 times greater in number compared the original analysis.Results:Recurrent stroke was observed in 182 (8.7%) patients. We identified seven novel SNPS on chromosome 1 in addition to our previous finding, rs6664786. Interestingly all chromosome 1 SNPs were located within the LINCO1362 gene. This gene has an acute change in expression in the presence of smoking even after adjustment of relevant clinical factors. Two novel SNPs were found on chromosome 16 located in gene desert nearest the pseudo-gene RNU6-21P in an intergenic region downstream of the Cadherin-8 (CDH8) gene. Both SNPs and RNU6-21P have no previously reported clinical relevance, except for their relative position to CDH8. CDH8 is highly expressed in brain tissue.Conclusions:We identified several novel SNPs associated with recurrent stroke. Capitalizing on genetic imputation advancements allows potential new insights and discoveries with past trial cohorts. Understanding these insights may provide further mechanistic knowledge of recurrent stroke to develop potential therapeutic targets.

Stroke, Volume 53, Issue Suppl_1, Page ATP56-ATP56, February 1, 2022. Accurate and timely prehospital stroke diagnosis and detection of large vessel occlusion (LVO) are essential to ensure stroke patients are transported to hospitals that offer emergent reperfusion therapies. However, symptom based prehospital stroke scales often fail to identify LVO. Thus, a need exists for cost-effective and portable diagnostic tools, such as portable electroencephalography (EEG) to improve the accuracy of prehospital stroke diagnosis.Hypotheses: 1) Quantitative EEG measures will differ between LVO and non-LVO stroke patients, particularly in regards to brain slowing (ratio of low to high frequency oscillatory brain power) and brain asymmetry (ratio between oscillations in the affected and unaffected hemisphere) 2) Combining EEG with prehospital stroke scales will improve the accuracy of LVO detection.We enrolled patients with acute suspected stroke on presentation to an emergency department at a comprehensive stroke centre. Patients were rapidly evaluated with the Los Angeles Motor Scale followed by a 3-minute resting-state EEG recording using a modified Muse EEG headband (InteraXon). The LVO diagnosis and the extent of cerebral blood flow abnormalities were determined from CT angiography and CT perfusion imaging performed in close temporal proximity to the EEG recording.The study enrolled 74 patients (n= 8 LVO, n=66 non-LVO, including stroke mimics). Initial analysis suggests that LVO patients have trends towards brain slowing, as measured by the delta alpha ratio (LVO: mean = 1.21, SEM = 0.03; non-LVO: mean = 1.19, SEM = 0.01; p-value = 0.34). Additionally, LVO patients showed a trend towards increased brain asymmetry from 6-8 Hz, suggesting physiological differences between hemispheres specific to the theta frequency (LVO: mean = 0.02, SEM = 0.006; non-LVO: mean = 0.01, SEM = 0.002; p-value = 0.13). Quantitative measures will be assessed using classification trees to determine which combination of EEG and clinical features is most predictive of LVO.In conclusion, acute differences in brain activity between LVO and non-LVO patients can be detected with portable EEG, which when combined with clinical stroke scales, have the potential to improve the diagnosis and triage of suspected stroke patients in a prehospital setting.

Stroke, Volume 53, Issue Suppl_1, Page ATMP59-ATMP59, February 1, 2022. Background/Purpose:Inherited thrombophilia testing in the acute inpatient setting is controversial and expensive, and in many cases does not change clinical management. We sought to determine the value of inpatient inherited thrombophilia testing for patients who presented with an isolated acute ischemic stroke or transient ischemic attack (TIA) without concurrent venous thromboembolism.Methods:We retrospectively analyzed a database comprising patients who were admitted for acute ischemic stroke or TIA in 2019 at Thomas Jefferson University Hospitals in Philadelphia, PA and had inherited thrombophilia testing performed during the hospital admission. Charts were reviewed to determine stroke risk factors, test results, and clinical management.Results:The study included 102 patients (median age 49.0 years, 53.9% female) who presented with acute ischemic stroke or TIA (including branch and central retinal artery occlusions) and underwent inpatient testing for factor V Leiden, prothrombin G20210A variant, hyperhomocysteinemia, PAI-1 elevation, and deficiencies of protein C and S and antithrombin. 406 tests were ordered, among which 14.0% resulted abnormal, and 41.2% of patients had at least one abnormal test. Patients without stroke risk factors were more likely to have an abnormal result (60.0% vs 35.1%, P = .028). However, 40% of abnormal tests were borderline positive antigen or activity assays that likely represented false positives. Considering only definitively positive results, there was no significant difference in the likelihood of a positive test in patients with vs without stroke risk factors (32.0% vs 26.0%, P = .557) or those under vs over age 50 years (30.2% vs 24.5%, P = .519). No patients with an abnormal result had their clinical management changed as a result. Charges for the tests totaled $182,994 USD.Conclusions:Inpatient inherited thrombophilia testing immediately following isolated acute arterial ischemic stroke or TIA was associated with high rates of false positive results and was expensive. Positive results did not change clinical management in a single case.

Stroke, Volume 53, Issue Suppl_1, Page AWP111-AWP111, February 1, 2022. Background and Aims:MRI is critical for diagnosing acute stroke and guiding candidate selection for potential reperfusion therapy. However, rapid stroke evaluation using MRI is often dissuaded by the time required for patients to travel to access-controlled, high-field (1.5-3T) systems. Advances in low-field MRI enable the acquisition of clinically valuable images at the bedside. We report neuroimaging in patients presenting to the Emergency Department (ED) with stroke symptoms using a low-field portable MRI (pMRI) device.Methods:A 64mT pMRI device was deployed in the Yale-New Haven Hospital ED from August 2020 to July 2021. Patients presenting as a “Stroke Code” or “Intracranial Hemorrhage Alert” with no MRI contraindications were scanned. Exams were performed at the bedside, in the vicinity of ED room equipment. Research staff acquired imaging via tablet, with images available immediately after acquisition. Sequences obtained and axial scan times (in minutes) included T1-weighted imaging (4:54), T2-weighted imaging (7:03), fluid-attenuated inversion recovery imaging (9:31), and diffusion-weighed imaging with apparent diffusion coefficient mapping (9:04). Patients’ demographic information, hours from the time of patients’ last known normal (LKN) to time of scan, and discharge diagnoses (determined from final imaging interpretation) were assessed.Results:pMRI exams were obtained on 54 patients (28 females, 51.9%; median age 71 years, 20-98 years). Discharge diagnoses included ischemic stroke (42.6%) no intracranial abnormality (31.5%), intraparenchymal hemorrhage (7.4%), atherosclerosis (7.4%), tumor (5.6%), subdural hematoma (3.7%), and intraventricular hemorrhage (1.9%). Patient LKN times ranged from 2 to 144 hours (median of 12 hours; 3 patients with no LKN excluded). The pMRI did not interfere with ED equipment and no significant adverse events occurred.Conclusion:We report the use of a pMRI for bedside neuroimaging in the ED. This approach suggests that pMRI may be viable for supporting rapid diagnosis and treatment candidate selection in patients presenting with stroke symptoms to the ED.