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Interventions for behaviour change and self-management in stroke secondary prevention: Protocol for an overview of reviews

2018-12-13, Lennon, Olive, Blake, Catherine, Booth, Jo, Pollock, Alex, Lawrence, Maggie

Background: Stroke secondary prevention guidelines recommend medication prescription and adherence, active education and behavioural counselling regarding lifestyle risk factors. To impact on recurrent vascular events, positive behaviour/s must be adopted and sustained as a lifestyle choice, requiring theoretically informed behaviour change and self-management interventions. A growing number of systematic reviews have addressed complex interventions in stroke secondary prevention. Differing terminology, inclusion criteria and overlap of studies between reviews makes the mechanism/s that affect positive change difficult to identify or replicate clinically. Adopting a two-phase approach, this overview will firstly comprehensively summarise systematic reviews in this area and secondly identify and synthesise primary studies in these reviews which provide person-centred, theoretically informed interventions for stroke secondary prevention. Methods: An overview of reviews will be conducted using a systematic search strategy across the Cochrane Database of Systematic Reviews, PubMed and Epistomonikas. Inclusion criteria: systematic reviews where the population comprises individuals post-stroke or TIA and where data relating to person-centred risk reduction are synthesised for evidence of efficacy when compared to standard care or no intervention. Primary outcomes of interest include mortality, recurrent stroke and other cardiovascular events. In phase 1, two reviewers will independently (1) assess the eligibility of identified reviews for inclusion; (2) rate the quality of included reviews using the ROBIS tool; (3) identify unique primary studies and overlap between reviews; (4) summarise the published evidence supporting person-centred behavioural change and self-management interventions in stroke secondary prevention and (5) identify evidence gaps in this field. In phase 2, two independent reviewers will (1) examine person-centred, primary studies in each review using the Template for Intervention Description and Replication (TIDieR checklist), itemising, where present, theoretical frameworks underpinning interventions; (2) group studies employing theoretically informed interventions by the intervention delivered and by the outcomes reported (3) apply GRADE quality of evidence for each intervention by outcome/s identified from theoretically informed primary studies. Disagreement between reviewers at each process stage will be discussed and a third reviewer consulted. Discussion: This overview will comprehensively bring together the best available evidence supporting person-centred, stroke secondary prevention strategies in an accessible format, identifying current knowledge gaps.

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An investigation of healthcare utilization and its association with levels of health literacy in individuals with chronic pain

2019-06, Mackey, Laura, Blake, Catherine, Squiers, Linda, Casey, Maire-Brid, Fullen, Brona M., et al.

Objective: Chronic pain patients are frequent and recurrent users of health services, which may have an impact on levels of health literacy (HL). Therefore, the aim of the present study was to investigate associations between healthcare utilization and varying levels of HL in individuals with and without chronic pain. Methods: A cross-sectional questionnaire was distributed in three pain clinics in Dublin, Ireland, comprising a demographic section, a validated HL assessment tool (Newest Vital Sign) and self-reported healthcare utilization in the previous year (i.e., general practitioner [GP] visits, accident and emergency room attendance, hospital services and allied health services). Patients with chronic pain, and a control group (no pain) were recruited. Results: Overall, 262 participants were recruited: those with chronic pain (n = 131) and controls (n = 131). Those in the chronic pain group were more likely to be female (p = 0.004), have less education (p = 0.01), be unable to work (p < 0.001), have a lower monthly income (p = 0.001), be more likely to have a medical card (i.e., free access to public health services) (p = 0.002) and have a greater number of comorbidities (p < 0.0001). Although bivariate analyses demonstrated increased healthcare utilization in chronic pain patients (i.e., GP visits, hospital services and allied therapies; p < 0.05), there was no difference in HL levels between groups in multivariate analysis (chronic pain: 54%, n = 71; control group 49%, n = 64; p = 0.39). Higher educational attainment, greater levels of income and being younger remained independently associated with higher levels of HL. Conclusions: Further research is needed to understand the nature of how HL is acquired, both from individual and organizational perspectives. Once this has been established, it may facilitate the development or advancement of current HL-sensitive management strategies.

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Musculoskeletal pain profile of obese individuals attending a multidisciplinary weight management service

2017-07, MacLellan, Grace A., Dunlevy, Colin, O'Malley, Emer, Blake, Catherine, Fullen, Brona M., et al.

Obesity is associated with numerous chronic diseases, including musculoskeletal (MSK) pain, which affects on quality of life (QoL). There is, however, limited research providing a comprehensive MSK pain profile of an obese cohort. This retrospective study used a patient database at a national weight management service. After ethical approval, anonymized patient data were statistically analyzed to develop a pain profile, investigate relationships between pain, sleep, and function, and explore variables associated with having low back pain (LBP) and knee pain. Overall, 915 individuals attended the weight management service from January 2011 to September 2015 [male, 35% (n = 318; confidence interval [CI] = 32-38); female, 65% (n = 597; CI = 62-68); mean age 44.6]. Mean body mass index was 50.7 kg/m 2 [class III obese (body mass index ≥40 kg/m 2), 92% (n = 835; CI = 91-94)]. Approximately 91% reported MSK pain: LBP, 69% (n = 539; CI = 65-72) [mean Numeric Rating Scale 7.4]; knee pain, 58% (n = 447; CI = 55-61) [mean Numeric Rating Scale 6.8]. Class III obese and multisite pain patients had lower QoL and physical activity levels, reduced sleep, and poorer physical function than less obese patients and those without pain (P < 0.05). Relationships were found between demographic, pain, self-report, psychological, and functional measures (P < 0.05). Patients who slept fewer hours and had poorer functional outcomes were more likely to have LBP; patients who were divorced, had lower QoL, and more frequent nocturia were more likely to have knee pain (P < 0.05). Multisite MSK pain is prevalent and severe in obese patients and is negatively associated with most self-report and functional outcomes. This high prevalence suggests that pain management strategies must be considered when treating obesity.

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Neuromuscular electrical stimulation (NMES) during recovery from exercise: A systematic review

2014-09, Malone, John, Blake, Catherine, Caulfield, Brian

The use of sub-tetanic low intensity neuromuscular electrical stimulation (NMES) for thepurpose of promoting recovery from exercise has increased in recent years. The aim of thissystematic review was to assess the effects of NMES on exercise recovery. A computeriseddatabase search of PubMed, CINAHL Plus, Sport Discus and Cochrane Library electronicdatabases was conducted for the time period Jan 1st 1970 to Mar 8th 2012. Only studieswhich used healthy uninjured humans and motor-threshold electrical stimulation compared toat least one other recovery modality for the purpose of promoting recovery from exercisewere eligible for selection. Thirteen studies satisfied the inclusion criteria and were includedfor analysis (11 randomised crossover trials (RXTs), 1 randomised control trial (RCT) and 1classified as other (OTH)). A quality assessment rating of the studies was performed usingan extended version of The Cochrane Collaborations Tool for Assessing Risk of Bias.Because of the heterogeneity of the study protocols, a qualitative review (best evidencesynthesis) was performed for all outcomes, while the results for blood lactate (BLa) were alsoincluded in a meta-analysis. Eight studies were classified as high quality, 4 as mediumquality, and one as low quality. Three studies found a positive outcome for a subjectivemeasure of muscle pain, 3 for BLa, one for lowering creatine kinase, and only one for aperformance parameter. The meta-analysis showed no evidence in favour of NMES vs.active (ACT) and mixed evidence vs. passive (PAS) recovery for BLa. In conclusion, whilstthere may be some subjective benefits for post-exercise recovery, evidence is not convincingto support NMES for enhancing subsequent performance.

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Exploring the Use of Mobile Athlete Self-report Measures in Elite Gaelic Games: A Qualitative Approach

2021-12-01, Duignan, Ciara, Slevin, Patrick, Caulfield, Brian, Blake, Catherine

Athlete self-report measures (ASRMs) are used in research and practice as an accurate, practical, and accessible method of athlete monitoring. Mobile adaptations of constructs from validated ASRM have increasingly been used for athlete monitoring in various sports settings; however, insights on the user experience and perceived value of these systems in the applied team sport setting have been limited. This study aimed to portray the experiences of stakeholders using a pre-existing mobile ASRM (M-ASRM) in elite Gaelic games. Twenty-one stakeholders in elite Gaelic games were recruited for this study (players n = 10, coaches and support staff n = 11). Subjects completed a semistructured interview with the lead researcher regarding their experience of using an M-ASRM in practice. Thematic analysis of the transcripts was conducted using NVivo 12 software. Results were defined under the themes of positive and negative user experience. Positive user experience was portrayed through M-ASRM uses and perceived value: communication and information disclosure, remote player monitoring, decision making and advanced planning, and player education and self-management. Negative user experience was portrayed through M-ASRM challenges: player adherence, player dishonesty, coach time and expertise requirements, and sociotechnical and system factors. Results outline the major uses of M-ASRM in elite Gaelic games and, importantly, highlight the key challenges experienced by stakeholders. These results can be applied by coaches, sports medicine professionals, and sports scientists using or intending to use an M-ASRM, providing key considerations to employ for effective use in team sport.

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The effectiveness of a stratified group intervention using the STarTBack screening tool in patients with LBP--a non randomised controlled trial

2013-12-05, Murphy, Susan, Blake, Catherine, Power, Camillus K., Fullen, Brona M.

Background: Low back pain (LBP) is costly to society and improving patient outcomes is a priority. Stratifying LBP patients into more homogenous groups is advocated to improve patient outcome. The STarT Back tool, a prognostic screening tool has demonstrated efficacy and greater cost effectiveness in physiotherapy settings. The management of LBP patients in groups is common but to date the utility of the STarT Back tool in group settings has not been explored. The aim of this study is to determine if the implementation of ‘stratified care’ when delivered in a group setting will lead to significantly better physical and psychological outcomes and greater cost effectiveness in LBP patients compared to a bestcare historical control group. Methods/Design: This study is a non randomised controlled trial. Low back pain patients recruited from the Waterford Primary Care area (population = 47,000) will be stratified into low, medium or high risk of persisting symptoms using the STarT Back Tool. Low risk patients will be offered a single one off education/exercise class offering positive messages on LBP management in line with recommended guidelines. Medium risk patients will be offered a 12 week group exercise/education intervention addressing their dominant physical obstacles to recovery. A 12 week group cognitive behavioural approach will be delivered to the high risk patients, characterised by the presence of high levels of psychosocial prognostic factors. These patients will be compared with a historical control group where therapists were blinded as to the risk stratification of patients and a generic group intervention was delivered to all patients, irrespective of their initial risk stratification. The primary outcome measure will be disability (Roland Morris Disability Questionnaire). Secondary outcomes will include back pain intensity (Visual Analogue Scale), distress (Distress and Risk Assessment Method), back beliefs (Back Beliefs Questionnaire), health status (Euroqol), global benefit (7 point likert scale), satisfaction (7 point likert scale), cost effectiveness and functional status. Outcome will be measured at baseline, 12 weeks and 6 months. Discussion: This paper details the rationale, design, methods, planned analysis and operational aspects of a study examining the utility of the STarT Back Tool as a 'stratification tool for targeted treatment' in a group intervention.

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Development of a Caregivers’ Support Platform (Connected Health Sustaining Home Stay in Dementia): Protocol for a Longitudinal Observational Mixed Methods Study

2019-08-28, Guisado-Fernández, Estefanía, Caulfield, Brian, Silva, Paula Alexandra, Mackey, Laura, Blake, Catherine, et al.

Background: Dementia disease is a chronic condition that leads a person with dementia (PwD) into a state of progressive deterioration and a greater dependence in performing their activities of daily living (ADL). It is believed nowadays that PwDs and their informal caregivers can have a better life when provided with the appropriate services and support. Connected Health (CH) is a new technology-enabled model of chronic care delivery where the stakeholders are connected through a health portal, ensuring continuity and efficient flow of information. CH has demonstrated promising results regarding supporting informal home care and Aging in Place, and it has been increasingly considered by researchers and health care providers as a method for dementia home care management. Objective: This study aims to describe the development and implementation protocol of a CH platform system to support informal caregivers of PwDs at home. Methods: This is a longitudinal observational mixed methods study where quantitative and qualitative data will be combined for determining the utility of the CH platform for dementia home care. Dyads, consisting of a PwD and their informal caregiver living in the community, will be divided into 2 groups: the intervention group, which will receive the CH technology package at home, and the usual care group, which will not have any CH technology at all. Dyads will be followed up for 12 months during which they will continue with their traditional care plan, but in addition, the intervention group will receive the CH package for their use at home during 6 months (months 3 to 9 of the yearly follow-up). Further comprehensive assessments related to the caregiver’s and PwD’s emotional and physical well-being will be performed at the initial assessment and at 3, 6, 9, and 12 months using international and standardized validated questionnaires and semistructured individual interviews. Results: This 3-year funded study (2016-2019) is currently in its implementation phase and is expected to finish by December 2019. We believe that CH can potentially change the PwD current care model, facilitating a proactive and preventive model, utilizing self-management–based strategies, and enhancing caregivers’ involvement in the management of health care at home for PwDs. Conclusions: We foresee that our CH platform will provide knowledge and promote autonomy for the caregivers, which may empower them into greater control of the care for PwDs, and with it, improve the quality of life and well-being for the person they are caring for and for themselves through a physical and cognitive decline predictive model. We also believe that facilitating information sharing between all the PwDs’ care stakeholders may enable a stronger relationship between them, facilitate a more coordinated care plan, and increase the feelings of empowerment in the informal caregivers.

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The impact of health literacy on health outcomes in individuals with chronic pain: a cross-sectional study

2019-09, Mackey, Laura, Blake, Catherine, Casey, Maire-Brid, Fullen, Brona M., et al.

Objective: To establish if health literacy (HL) is linked to poorer outcomes and behaviours in patients with chronic pain. Design: A prospective cross-sectional observational study. Setting: Multidisciplinary out-patient pain clinics in three university teaching hospitals. Patients: New patients (n = 131) referred to the pain clinic with a history of chronic pain (>12 weeks). Methods: A questionnaire was distributed to chronic pain patients attending their first appointment. Those eligible for inclusion were newly referred patients who had pain lasting longer than three months. The questionnaire comprised the following sections: demographics, chronic pain status and disease-related knowledge, quality of life (SF-36), beliefs (Beliefs About Pain Control Questionnaire), and a validated HL tool (Newest Vital Sign). Results: Of the 131 participants recruited, 54% had inadequate HL. The group was subsequently stratified according to HL level. In bivariate analysis, inadequate HL was associated with older age (p < 0.001), being unemployed or retired (p = 0.005), less education (p < 0.001), lower income, increased comorbidities (p = 0.038), being less likely to utilise allied health services (p = 0.001), poorer disease-related knowledge (p = 0.002), and poorer beliefs about pain (p < 0.05). In multivariate analysis, disease-related knowledge (OR 2.5, 95%CI 1.0 to 6.3, p = 0.05) and beliefs about pain (B = −2.3, S.E = 0.9, p = 0.01) remained independently associated with HL. Conclusion: Inadequate HL is prevalent in chronic pain patients, and may impact on the development of certain characteristics necessary for effective self-management.

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Neuromuscular electrical stimulation: no enhancement of recovery from maximal exercise

2014-09, Caulfield, Brian, Malone, John, Blake, Catherine

Purpose: To investigate the use of neuromuscular electrical stimulation (NMES) during acute recovery between 2 bouts of maximal aerobic exercise. Methods: On 3 separate days, 19 trained male cyclists (28 ± 7 y, 76.4 ± 10.4 kg, power output at maximal aerobic power [pVo2max] 417 ± 44 W) performed a 3-min maximal cycling bout at 105% PVo2max before a 30-min randomly assigned recovery intervention of passive (PAS: resting), active (ACT: 30% PVo2max), or NMES (5 Hz, 4 pulses at 500 μs). Immediately afterward, a cycle bout at 95% PVo2max to exhaustion (TLIM) was performed. Heart rate (HR) and blood lactate (BLa) were recorded at designated time points. Data were analyzed using repeated-measures ANOVA with a Tukey honestly significantly different post hoc test. Statistical significance threshold was P < .05. Results: The TLIM was significantly shorter for NMES than for ACT (199.6 ± 69.4 s vs 250.7 ± 105.5 s: P = .016) but not PAS recovery (199.6 ± 69.4 s vs 216.4 ± 77.5 s: P = .157). The TLIM was not significantly different between ACT and PAS (250.7 ± 105.5 s vs 216.4 ± 77.5 s: P = .088). The decline in BLa was significantly greater during ACT than NMES and PAS recovery (P < .001), with no difference between NMES and PAS. In addition, HR was significantly higher during ACT than NMES and PAS recovery (P < .001), with no difference between NMES and PAS. Conclusions: NMES was less effective than ACT and comparable to PAS recovery when used between 2 bouts of maximal aerobic exercise in trained male cyclists.

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The impact on sleep of a multidisciplinary cognitive behavioural pain management programme: a pilot study

2011-01-10, Cunningham, Jennifer M., Blake, Catherine, Power, Camillus K., Fullen, Brona M., et al.

Background: Reduced sleep quality is a common complaint among patients with chronic pain, with 50-80% of patients reporting sleep disturbance. Improvements in pain and quality of life measures have been achieved using a multidisciplinary cognitive behavioural therapy pain management programme (CBT-PMP) that aims to recondition attitudes to pain, and improve patients' self-management of their condition. Despite its high prevalence in patients with chronic pain, there is very limited objective evidence for the effect of this intervention on sleep quality. The primary research objective is to investigate the short-term effect of a multidisciplinary CBTPMP on subjective (measured by Pittsburg Sleep Quality Index) and objective sleep quality (measured by Actigraphy) in patients with chronic pain by comparison with a control group. The secondary objectives will investigate changes in function and mood, and then explore the relationship between objective and subjective sleep quality and physical and psychological outcome measures. Methods/Design: Patients who fulfil the inclusion criteria for attendance on the multidisciplinary CBT-PMP in the Adelaide and Meath Hospital, Tallaght, Dublin and are currently listed on the PMP waiting list will be invited to participate in this pilot study. Potential patients will be screened for sleep disturbance [determined by the Pittsburgh Sleep Quality Index (PSQI)]. Those patients with a sleep disturbance (PSQI >5) will be assigned to either the intervention group (immediate treatment), or control group (deferred treatment, i.e. the PMP they are listed for is more than six months away) based on where they appear on the waiting list. Baseline measures of sleep, function, and mood will be obtained using a combination of self-report questionnaires (the Hospital Anxiety and Depression Scale, the Short Form 36 health survey, the Pittsburgh Sleep Quality Index, the Tampa Scale for Kinesiophobia), and functional outcome measures. Sleep will be measured for seven days using actigraphy (Actiwatch 7). These measures will be repeated after the four week multidisciplinary cognitive behavioural therapy pain management programme, and at a two month follow-up. The waiting list control group will be assessed at baseline, and two months later. Analysis for the primary outcome will include between group differences of subjective and objective sleep parameters from baseline to follow-up using Independent T-tests or Mann-Whitney U tests. The secondary outcomes establishing relationships between the sleep variables and physical and psychological outcome measures will be established using multiple linear regression models. Discussion: This pilot study will evaluate the impact of a multidisciplinary CBT-PMP on both subjective and objective measures of sleep in patients with chronic pain and provide guidance for a larger clinical trial. Trial Registration: Current controlled trial ISRCTN: ISRCTN74913595