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PubMed2001

Evaluating an integrated approach to clinical quality improvement: clinical guidelines, quality measurement, and supportive system design.

BACKGROUND: Implementing clinical practice guidelines to change patient outcomes presents a challenge. Studies of single interventions focused on changing provider behavior demonstrate modest effects, suggesting that effective guideline implementation requires a multifaceted approach. Traditional biomedical research designs are not well suited to evaluating systems interventions. OBJECTIVES: RAND and the Army Medical Department collaborated to develop and evaluate a system for implementing guidelines and documenting their effects on patient care. RESEARCH DESIGN: The evaluation design blended quality improvement, case study, and epidemiologic methods. A formative evaluation of implementation process and an outcome evaluation of patient impact were combined. SUBJECTS: Guidelines were implemented in 3 successive demonstrations targeting low back pain, asthma, and diabetes. This paper reports on the first wave of 4 facilities implementing a low back pain guideline. METHODS: Organizational climate and culture, motivation, leadership commitment, and resources were assessed. Selected indicators of processes and outcomes of care were compared before, during, and after guideline implementation at the demonstration facilities and at comparison facilities. Logistic regression analysis was used to test for guideline effects on patient care. RESULTS: Process evaluation documented varied approaches to quality improvement across sites. Outcome evaluation revealed a significant downward trend in the percentage of acute low back pain patients referred to physical therapy or chiropractic care (10.7% to 7.2%) at demonstration sites and no such trend at control sites. CONCLUSIONS: Preliminary results suggest the power of this design to stimulate improvements in guideline implementation while retaining the power to evaluate rigorously effects on patient care.

Adolescent↗
PubMed1998

Bilateral tubo-ovarian abscesses four years after total abdominal hysterectomy.

BACKGROUND: Pelvic inflammatory disease (PID) is a common gynecologic disorder. One known complication of PID is tubo-ovarian abscess (TOA) formation. The predominant theory on TOA formation postulates that an ascending infection from the cervix through the uterus to the fallopian tubes and ovaries results in abscess formation. Other theories include seeding via a hematogenous infection, diverticular disease, and appendicitis. CASE: A 39-year-old female patient with abdominal pain was referred to our institution and was found to have a pelvic mass. After a thorough evaluation, surgical exploration revealed the presence of TOA. No evidence of gastrointestinal disease was present. The patient's history was significant for an uncomplicated total abdominal hysterectomy for benign disease of the uterus four years prior. Abscess cultures grew Streptococcus intermedius. CONCLUSION: This case reports the rare occurrence of TOA in a patient who had undergone an abdominal hysterectomy four years prior to presentation. If the patient reports a surgical history of prior hysterectomy, TOA is often stricken from consideration. Although unlikely, adnexal abscess formation should be considered in the differential diagnosis of a patient with abdominal pain and a pelvic mass, even with a remote history of hysterectomy.

Abscess↗
PubMed1998

Exertional compartment syndrome of the upper extremity.

Exertional compartment syndrome is characterized by intracompartmental pressures that rise transiently following repetitive motion or exercise, thereby producing temporary, reversible ischemia, pain, weakness, and, occasionally, neurologic deficits. The exact cause or pathogenesis remains unclear; a disturbance of microvascular flow caused by elevated intramuscular pressure leads to tissue ischemia, depletion of high-energy phosphate stores, and cellular acidosis. Anatomic contributing factors may include a limited compartment size, increased intracompartmental volume, constricted fascia, loss of compartment elasticity, poor venous return, or increased muscle bulk. The diagnosis is suspected based on history and confirmed with physical examination and intramuscular pressure evaluation before and after exercise (stress test). Differential diagnosis includes claudication or other vascular abnormalities, myositis, tendinitis, periostitis, chronic strains or sprains, stress fracture, other compression or systemic neuropathies, and cardiac abnormalities with angina or referred extremity pain. Initial treatment includes activity modification; refractory symptoms can be managed with elective fasciotomy.

Chronic Disease↗
PubMed1989

Shoulder injuries in archery.

Twenty-one elite-calibre archers (M = 12, F = 9) were investigated concerning all past and present archery-related shoulder injuries, using a questionnaire and physical examination. The questionnaire revealed that 11 of 21 archers had complained of significant shoulder injuries either currently or during their careers. While 9/12 men never had shoulder problems during an average of 13.5 years, only 4/9 women escaped injury during a mean 10.9 year competitive career. Deficits in training programs were noted, including lack of training and non-specific exercises. Clinical examination demonstrated shoulder asymmetry and decreased flexibility in the drawing arm (DA) shoulder. Functional testing revealed a positive impingement sign in 6/21 DA shoulders. Supraspinatus testing showed abnormalities in 4/21 DA shoulders. Pain was referred posteriorly with the impingement maneuver in 5/21 DA shoulders and abnormal external rotation testing was observed in 8/21 DA shoulders. Generally, the females had proportionally more signs and symptoms of shoulder injury than the men, especially involving the DA shoulder. Testing implicated supraspinatus impingement/tendonitis and infraspinatus/teres minor traction tendonitis. These clinical findings correlated with cadaver prosection observations.

Acromion↗
PubMedDate not supplied

Power spectra of sternocleidomastoids, splenius capitis, and upper trapezius in oblique exertions.

BACKGROUND CONTEXT: There is relatively little known concerning the spectral profile of the cervical muscles, despite the fact that neck injury and pain are quite prevalent. PURPOSE: The objective of the study was to calculate and study the power spectral characteristics of the sternocleidomastoids, splenii capitis and upper trapezii in anterolateral flexion and posterolateral extension in a ramp contraction. STUDY DESIGN/SETTING: In a laboratory setting experiments were conducted to record surface electromyographic (EMG) data from six cervical muscles and power spectral variables obtained. PATIENT SAMPLE: Forty normal and healthy young adults (21 men, 19 women). OUTCOME MEASURES: Power spectral of EMG signals. METHODS: EMG data for the left and right isometric anterolateral flexion and posterolateral extension were acquired from the sternocleidomastoids, splenii capitis and upper trapezius bilaterally. The subjects were seated in an upright posture and exerted left and right anterolateral flexor and posterolateral extensor efforts from rest to their maximal voluntary contraction in a gradual linear ramp fashion using visual feedback as a guide. The force exerted and the surface EMG data were sampled at 1 kHz at every 10th percentile grade of contraction and the EMG data were subjected to the Fast-Fourier transform analysis. The median frequency (MF), mean power frequency (MPF), peak power and total power of all six cervical muscles were analyzed. RESULTS: In the anterolateral flexion the ipsilateral sternocleidomastoid and splenius capitis had a wider band of frequency, which further widened with increasing grade of contraction. The trapezius did not engage in the same manner or to the same magnitude. The MF of the sternocleidomastoid in the anterolateral flexion in both genders progressively increased, the splenius capitis remained relatively unchanged, and the upper trapezius declined with the increasing grades of contraction. CONCLUSIONS: There is no significant difference between the genders in spectral profile. There is a bilateral symmetry in spectral profile with reference to activity; however, they are significantly different in different activities for the same muscles. With increasing magnitude of contraction power, spectral density distribution increases and the median frequency decreases. These results can serve as a useful reference for painful necks. Restoration of power spectral characteristics may indicate normalcy, which cannot be gleaned by other EMG or force variables.

Adult↗
PubMed1999

Is chronic non-specific low back pain chronic? Definitions of a problem and problems of a definition.

BACKGROUND: Chronic low back pain (LBP) accounts for the majority of the disability and costs for LBP. However, the definition of chronicity is unclear. AIM: To elicit practitioners' definitions of chronic LBP patients, both in general and in the patients they were treating; to assess the most common characteristics of these practitioners' chronic LBP patients; and to assess the stability of chronicity in a sample of the general population. METHOD: Semi-structured interviews were conducted with 33 practitioners working in private practice, 71 LBP patients and their therapists, and 252 employees of a chain store who were assessed yearly in a prospective study. RESULTS: The therapists' definitions of chronic LBP patients generally included psychosocial aspects. Only physical symptoms and signs were stressed in the patients they were treating. These patients displayed common characteristics with reference to pain, functional problems, and contact with health care services. Duration of symptoms was not sufficient to define chronicity. In the employee population, chronicity defined according to pain duration was unstable. However, the same was true when chronicity was measured according to the criteria defined in the patient population. CONCLUSION: There is a discrepancy between theory and practice regarding the definition of chronic LBP. This discrepancy concerns not only the literature but also clinical practice itself. The term 'chronic' LBP as currently used is therefore equivocal.

Adult↗
PubMed1980

The scintigraphic evaluation of hip pain in children.

Thirty-eight patients (28 boys and 10 girls) with hip pain were referred for bone scans. In 7 of 8 with Legg-Calvé-Perthes disease, there was decreased uptake of the radiopharmaceutical in the proximal femoral epiphysis; the other had radiographic evidence of joint destruction and showed increased uptake. Three patients with abnormal scans had normal x-rays with Gaucher's disease, toxic synovitis, and Legg-Calvé-Perthes disease, respectively. One patient with avascular necrosis associated with steroid therapy had increased uptake, possibly due to revascularization. Those with toxic synovitis had either normal bone scans for showed a slight generalized increase around the hip joint. It is speculated that the latter may represent those who later present with Legg-Calvé-Perthes. The bone scan is useful for the early detection of Legg-Calvé-Perthes disease in patients with hip pain.

Adolescent↗
PubMed1994

The straight cervical spine: does it indicate muscle spasm?

The loss of cervical lordosis in radiographs of patients presenting with neck pain is sometimes ascribed to muscle spasm. We performed a cross-sectional study of the prevalence of 'straight' cervical spines in three populations: 83 patients presenting to an accident department with acute neck pain, 83 referred to a radiology department with chronic neck problems, and 80 radiographs from a normal population survey carried out in 1958. Curvature was assessed on lateral radiographs both subjectively and by measurement. The prevalence of 'straight' cervical spines was 19% in the acute cases and 26% in the chronic cases. The 95% confidence interval for the difference was -6.4% to +19.3%. In the normal population 42% showed a straight spine, but a further third of these films had been taken in a position of cervical kyphosis; this probably reflects a difference in positioning technique. Women were more likely than men to have a straight cervical spine, with an odds ratio of 2.81 (95% CI 1.23 to 6.44). Our results fail to support the hypothesis that loss of cervical lordosis reflects muscle spasm caused by pain in the neck.

Acute Disease↗
PubMed2003

Referred sensations in patients with complex regional pain syndrome type 1.

OBJECTIVES: This study sought to explore and characterize referred sensations (RS) in patients with complex regional pain syndrome (CRPS) type 1 and test the hypothesis that pain in CRPS is associated with central sensory changes. METHODS: Subjects underwent standardized neurological examination involving light touch, pinprick and vibration sense with eyes closed and then with eyes open. The subjects described the location and sensation emanating from the stimulated site and whether they experienced any sensations (similar or different) elsewhere. RESULTS: Five of 16 subjects recruited demonstrated RS. These were experienced in real time, were modality specific (touch and pinprick) and were located on the body part immediately adjacent, on Penfield's cortical homunculus, to the stimulated site. The RS were diminished or absent when the subject visualized the stimulated area. They disappeared when stimulation ceased and on clinical improvement. CONCLUSIONS: This is the first report of RS in CRPS and provides further evidence of central reorganization in what was previously thought to be a peripheral disorder.

Adult↗
PubMed1993

'Mirror pain' in the formalin test: behavioral and 2-deoxyglucose studies.

Subcutaneous injection of a dilute formaldehyde solution (5 or 10%) into a hind paw induced, in the majority of rats, the appearance of 'mirror pain': licking the contralateral untreated hind paw 10-60 min after injection. Contralateral licking activity was much less frequent than the ipsilaterally directed one, but the overall intensities of the two responses were positively correlated. Qualitatively, the two behaviours were similar. Functional activity levels of the lumbar spinal cord, as revealed by the 2-deoxyglucose (2-DG) technique, were increased bilaterally over the first hour after unilateral hind limb formalin injection in unanesthetized, freely moving rats. The enhancement of the [14C]2-DG uptake could be detected both in dorsal and ventral horns, as well as in the gray matter surrounding the central canal, and the anterolateral and dorsolateral funiculi. These metabolic changes may reflect an enhancement of the functional activity of both interneuronal pools and units projecting to supraspinal centers, giving rise to a referred contralateral pain.

Animals↗
PubMed1993

[Neuro-reflexotherapy intervention in the treatment of non specified low back pain: a randomized, controlled, double-blind clinical trial].

BACKGROUND: Nonspecific low back pain is a very common disorder for which no completely satisfactory treatment has been established. A randomized, double-blind, controlled clinical trial was design to assess the efficacy of neuro-reflexotherapic intervention in the treatment of this condition. METHODS: Ninety-one patients with a confirmed diagnosis of nonspecific low back pain were referred for treatment from primary health care facilities in the Spanish National Health System. A total of 43 patients were assigned to the control group and 48 to the treatment group. Patients in the treatment group received a single neuro-reflexotherapic intervention. Patients in the control group underwent a similar procedure, although inappropriate zones were stimulated. Patients in both groups were allowed to continue drug and physiotherapy treatments prescribed by their general practitioners. According to the design the study was ended when statistically significant and clinically evaluable results were obtained in an analysis carried out half way through the study. RESULTS: Participants underwent clinical evaluations on three occasions: immediately prior to intervention, immediately after and on day 30 afterwards. Patients in the treatment group showed immediate clinically and statistically significant improvements (p < 0.0001) in pain, muscular contracture and mobility, allowing them to discontinue pharmacological treatment and keeping them free of symptoms during the study period. CONCLUSIONS: According to results of this study, neuro-reflexotherapic intervention has proved to be an effective method for treating low back pain.

Adult↗
PubMed1995

Prevalence of abuse and dependency in chronic pain patients.

A series of 414 chronic pain patients referred to Are Hospital, Are, Sweden, for evaluation and rehabilitation were administered a structured diagnostic interview to detect alcohol and drug misuse and dependence according to DSM-III-R criteria. A total of 97 (23.4%) met criteria for active alcohol, analgesic, or sedative misuse or dependency; an additional 39 (9.4%) met criteria for a remission diagnosis. Current dependency was most common for analgesics (12.6%) followed by alcohol (9.7%) and sedatives (7.0%).

Adolescent↗
PubMedDate not supplied

Secondary prevention of work-related disability in nonspecific low back pain: does problem-solving therapy help? A randomized clinical trial.

OBJECTIVES: Given the individual and economic burden of chronic work disability in low back pain patients, there is a need for effective preventive interventions. The aim of the present study was to investigate whether problem-solving therapy had a supplemental value when added to behavioral graded activity, regarding days of sick leave and work status. DESIGN: Randomized controlled trial. PATIENTS AND SETTING: Employees who were recently on sick leave as a result of nonspecific low back pain were referred to the rehabilitation center by general practitioner, occupational physician, or rehabilitation physician. Forty-five employees had been randomly assigned to the experimental treatment condition that included behavioral graded activity and problem-solving therapy (GAPS), and 39 employees had been randomly assigned to behavioral graded activity and group education (GAGE). OUTCOME MEASURES: Days of sick leave and work status. Data were retrieved from occupational health services. RESULTS: Data analyses showed that employees in the GAPS group had significantly fewer days of sick leave in the second half-year after the intervention. Moreover, work status was more favorable for employees in this condition, in that more employees had a 100% return-to-work and fewer patients ended up receiving disability pensions one year after the intervention. Sensitivity analyses confirmed these results. CONCLUSIONS: The addition of problem-solving therapy to behavioral graded activity had supplemental value in employees with nonspecific low back pain.

Adult↗
PubMed1982

Tethered cord syndrome in adults.

Patients with tethered cord syndrome (TCS) rarely have symptomatic onset in adulthood. Twenty-three adult patients with TCS were studied with respect to the clinical, radiological, and pathological features of this syndrome. Specific circumstances involving either additional tugging of the already tight conus, narrowing of the spinal canal, or direct trauma to the back or buttocks precipitated symptomatic onset in 60% of patients. Diffuse and non-dermatomal leg pain, often referred to the anorectal region, was the most common presenting symptom. Progressive sensorimotor deficits in the lower extremities as well as bladder and bowel dysfunction were also common findings; but, unlike TCS in children, progressive foot and spinal deformities were not seen. As in TCS with onset in childhood, the most common tethering lesions were thickened filum, intradural lipoma, and fibrous adhesions. The degree of cord traction, rather than the type or distribution of the tethering lesions, probably determines the age of symptom onset: less severe traction remains asymptomatic in childhood but results in neurological dysfunction in later life due to repeated tugging of the conus during natural head and neck flexion, or when abnormal tension is aggravated by trauma or spondylotic canal stenosis. Metrizamide myelography revealed the diagnosis of tethered conus in most cases, but the addition of computerized tomographic imaging provided valuable structural details concerning the tethering lesion. The surgical outcome was gratifying in relation to pain and motor weakness but disappointing in the resolution of bowel and bladder dysfunction. Early diagnosis and adequate release of the tethered conus are the keys to successful management.

Adolescent↗
PubMed1999

Restorative exercise for clinical low back pain. A prospective two-center study with 1-year follow-up.

STUDY DESIGN: A comparison of treatment of 412 patients with chronic back pain at two separate centers using the same treatment protocols and outcome measures. Outcome was defined by specific strength testing; Short Form-36 scores at intake, discharge, and 1-year follow-up; self-appraisal of improvement at discharge and in a 1-year follow-up; and reuse of health care services after discharge. OBJECTIVES: To investigate the efficacy of standardized treatment methods using isolated lumbar strength testing and strengthening based on progressive protocols using specific equipment. Comparison of results should clarify the effect of the treatment center versus the efficacy of standardized protocols. SUMMARY OF BACKGROUND DATA: There has been little support in the scientific literature for exercise programs based on standardized protocols. The use of specialized equipment to achieve intense specific exercise also has been poorly supported. Overall health benefit has not often been related to specific improvement in strength. METHODS: More than 400 individuals with chronic back pain were evaluated at the initiation of treatment, discharge, and 1 year after discharge. Measures of efficacy were based on Short Form-36 scores, self-appraisal of improvement, and reuse of health care services after discharge. Study participants were patients with chronic back pain consecutively referred to each treatment site and underwritten by a variety of payers, including workers' compensation, Medicare, and private insurance. RESULTS: Overall response during the course of the program and at 1-year follow-up was similar between the two centers. Similar proportions of participants at each site demonstrated improvement in SF-36 scores, self-appraisal of improvement, and reuse of health care services. CONCLUSIONS: Standardized protocols using specific strength and measurement equipment can achieve similar benefits at different sites.

Adult↗
PubMed2002

Joint space narrowing and relationship with symptoms and signs in adults consulting for hip pain in primary care.

OBJECTIVE: To study whether clinical symptoms and signs can predict radiological osteoarthritis (OA) of the hip in primary care patients with hip pain. METHODS: Consecutive patients (n = 220) aged 50 years or older consulting the general practitioner for hip pain and referred for radiological investigation underwent a standardized history, radiological, laboratory, and physical examination. Radiological OA was confirmed with joint space < or = 2.5 mm. Additionally, a more stringent definition was used (< or = 1.5 mm). The relationship between radiological OA and possible clinical symptoms/signs of OA was tested. Combinations of clinical symptoms/signs that had shown an independent relationship with radiological OA in multivariate analyses were tested for their predictive value. RESULTS: Radiological OA (joint space < or = 2.5 mm) of the (more) symptomatic hip was present in 35.5% of the study population and more severe OA (joint space < or = 1.5 mm) in 11.4%. Presence of 4 specific symptoms/signs from history and examination showed a positive predictive value (PPV) of 73% (specificity 91%, sensitivity 45%) for radiological OA. When 5 specific symptoms/signs were present, the PPV for the more severe radiological OA was 82% (specificity 98%, sensitivity 72%), and when 6 or 7 specific symptoms/signs were present the PPV was 100% (specificity 100%, sensitivity 40% and 8%, respectively). Negative predictive values were high for almost all combinations. CONCLUSION: In primary care patients with hip pain, clinical symptoms and signs can to a moderate extent predict radiological OA and to a large extent more severe radiological OA.

Female↗
PubMed2003

[New urodynamic data of sensory urgency in women].

OBJECTIVES: Irritative bladder symptoms are common in females. Besides, micturition disorders are occasionally associated. Sensory urgency is one of the syndromes that include the symptoms. This entity is a urodynamic condition defined by the presence of pain or urgency during the filling phase without associated involuntary detrusor contractions. Although it is well defined urodynamically, the corresponding nosological entity is unknown. The objective of this study is to check if it has any relationship with the capability of the abdominal press to participate during micturition. METHODS: We perform a transversal study comparing a group of 25 females (mean age 50.2 yr.) with the diagnosis of sensory urgency and a group of 48 patients paired by age. Urodynamic data from both groups were reviewed, and the existence of significant differences was determined for flowmetry, bladder capacity (cystometry), and participation of the abdominal press during voiding (voiding flow-detrusor pressure test). RESULTS: Patients with sensory urgency showed significantly lower maximum and mean flow rates than controls. Bladder capacity was similar in both groups, but bladder capacity at first desire to void was significantly lower in the sensory urgency group. No significant differences were observed between the groups on participation of the abdominal press. However, if the comparison was performed between the subgroup of patients with sensory urgency who also referred suprapubic pain during filling and controls, then there was a significantly higher participation of the abdominal press during voiding in this group. CONCLUSIONS: Data from this study are compatible with the hypothesis that sensory urgency is associated with bladder contractile capacity alterations. This association would be more evident in the group of patients in which sensory urgency is accompanied by hypogastric pain during filling, which could constitute a subgroup with higher progression risk.

Cross-Sectional Studies↗