Central sensitization (CS), a mechanism explaining the persistence of symptoms, has been the focus of many research projects. Explanations given to patients with chronic pain are often based on this ...mechanism. It is hypothesized that CS also plays an important role in the persistence of medically unexplained symptoms (MUS). However, definitions and operationalizations of CS vary. We conducted a systematic review of definitions, operationalizations and measurement instruments of CS.
We searched in PubMed, EMBASE, PsycINFO, Cinahl and The Cochrane Library till September 2017 and included papers that addressed CS in relation to chronic pain and/or MUS. Two reviewers independently selected, analysed and classified information from the selected publications. We performed a thematic analysis of definitions and operationalizations. We listed the measurement instruments.
We included 126 publications, 79 publications concerned chronic pain, 47 publications concerned MUS. Definitions of CS consistently encompass the theme hyperexcitability of the central nervous system (CNS). Additional themes are variably present: CNS locations, nature of sensory input, reduced inhibition and activation and modulation of the NDMA receptor. Hyperalgesia and allodynia are widely mentioned as operationalizations of CS. Quantitative sensory testing (QST) and (f)MRI are the most reported measurement instruments.
There is consensus that hyperexcitability is the central mechanism of CS. Operationalizations are based on this mechanism and additional components. There are many measurement instruments available, whose clinical value has still to be determined. There were no systematic differences in definitions and operationalizations between the publications addressing MUS and those addressing chronic pain.
•We systematically reviewed definitions of central sensitization (CS).•Main theme in the definitions is hyperexcitability of the central nervous system.•We found eight different operationalizations.•Findings were similar in chronic pain and medically unexplained symptoms research.•The clinical value of measurement instruments for CS has yet to be established.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
This systematic review and meta-analysis showed a significant reduction of (major) osteoporotic fractures and hip fractures after screening using fracture risk assessment and bone densitometry ...compared with usual care. The results indicate that screening is effective for fracture risk reduction, especially hip fractures. To perform a systematic review and meta-analysis of population screening for high fracture risk on fracture prevention compared with usual care. MEDLINE and Embase were searched for studies published until June 20th 2019. Randomized studies were selected that screened for high fracture risk using at least bone densitometry, screened in a general population, provided subsequent treatment with anti-osteoporosis medication, had a usual care group as comparator, and had at least one fracture-related outcome (all fractures, (major) osteoporotic fractures, or hip fractures). The primary assessment was the hazard ratio (HR) for fracture-related outcomes. All-cause mortality was a secondary outcome. Random-effects models were used to estimate pooled HRs. We identified 1186 potentially eligible articles and included three randomized studies: the ROSE study, the SCOOP study, and the SOS with a total number of
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= 42,009 participants. Respectively, 11%, 15%, and 18% of the participants in the intervention group started medication. Meta-analysis showed a statistically significant and clinically relevant reduction of osteoporotic fractures (HR = 0.95, 95% confidence interval (CI) = 0.89–1.00), major osteoporotic fractures (HR = 0.91; 95%CI = 0.84–0.98), and hip fractures (HR = 0.80; 95%CI = 0.71–0.91), but no reduction of all fractures (HR = 0.95; 95%CI = 0.89–1.02). The pooled HR for the secondary outcome all-cause mortality was 1.04 (95% CI = 0.95–1.14). Numbers needed to screen to prevent one fracture were 247 and 272 for osteoporotic fractures and hip fractures, respectively (corresponding to 113 and 124 performed bone densitometry examinations, and 25 and 28 persons being treated). This meta-analysis showed that population screening is effective to reduce osteoporotic fractures and hip fractures. Implementation of screening in older women should be considered as serious option to prevent osteoporotic fractures, especially hip fractures.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
In primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal ...costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies.
We searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality.
A total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes.
This review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions.
Study methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
While effective general practitioner (GP)–patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed ...to identify barriers and facilitators for GP–patient communication in palliative care. In a systematic review seven computerized databases were searched to find empirical studies on GP–patient communication in palliative care. Fifteen qualitative studies and seven quantitative questionnaire studies were included. The main perceived barriers were GPs’ lack of availability, and patients’ and GPs’ ambivalence to discuss ‘bad prognosis’. Main perceived facilitators were GPs being available, initiating discussion about several end-of-life issues and anticipating various scenarios. Lack of availability and failure to discuss former mistakes appear to be blind spots of GPs. GPs should be more forthcoming to initiate discussions with palliative care patients about prognosis and end-of-life issues. Empirical studies are needed to investigate the effectiveness of the perceived barriers and facilitators.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Studies based on pharmacy medication records have shown suboptimal adherence and persistence of osteoporosis treatment with oral bone sparing drugs (OBSD). Little is known about adherence and ...persistence of OBSD treatment in primary care. We assessed adherence and persistence of OBSD use of patients in general practices and identified associated factors.
Using electronic medical records, adherence and persistence of newly prescribed treatment with OBSD in patients from 16 general practices was retrospectively assessed. The Medication Possession Ratio (MPR) was calculated as a proxy for adherence (MPR > 75%), persistence rates were estimated using survival analysis. Determinants of adherence and persistence using logistic regression and Cox regression analysis were assessed.
OBSD treatment was initiated in 957 patients. Seventy-five percent and 45% of the patients persisted OBSD treatment for one and five years, respectively. Being adherent in the first year decreased the risk of long-term non-persistence hazard ratio (HR) 0.41; 95% confidence interval (CI) 0.3-0.57; P < 0.001. Patients receiving the majority of their prescriptions by a specialist tended to be more non-persistent (HR 1.37; 96%; CI 0.96-1.94; P = 0.08). Adherence was 62.5% in the first year and 60.8% in the overall treatment period. Non-adherence was associated with the specialist being the main prescriber odds ratio (OR) 3.76; 95% CI 2.43-5.82; P < 0.001 and younger age (<65 years, OR 1.44; 95% CI 1.01-2.08; P = 0.04).
Older age of the patients and the GP prescribing the majority of medication were associated with better adherence and persistence. Good adherence in the first prescription year was associated with better persistence.
Objective To compare the effects of a minimal intervention strategy aimed at assessment and modification of psychosocial prognostic factors and usual care for treatment of (sub)acute low back pain in ...general practice. Design Cluster randomised clinical trial. Setting 60 general practitioners in 41 general practices. Participants 314 patients with non-specific low back pain of less than 12 weeks' duration, recruited by their general practitioner. Interventions In the minimal intervention strategy group the general practitioner explored the presence of psychosocial prognostic factors, discussed these factors, set specific goals for reactivation, and provided an educational booklet. The consultation took about 20 minutes. Usual care was not standardised. Main outcome measures Functional disability (Roland-Morris disability questionnaire), perceived recovery, and sick leave because of low back pain assessed at baseline and after 6, 13, 26, and 52 weeks. Results The dropout rate was 8% in the minimal intervention strategy group and 9% in the usual care group. Multilevel analyses showed no significant differences between the groups on any outcome measure during 12 months of follow-up in the whole group or in relevant subgroups (patients with high scores on psychosocial measures at baseline or a history of frequent or prolonged low back pain). Conclusion This study provides no evidence that (Dutch) general practitioners should adopt our new treatment strategy aimed at psychosocial prognostic factors in patients with (sub)acute low back pain. Further research should examine why our new strategy was not more effective than usual care.
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
Burnout is highly prevalent in GPs and can have a negative influence on their wellbeing, performance, and patient care. Mindfulness-based stress reduction (MBSR) may be an effective intervention to ...decrease burnout symptoms and increase wellbeing.
To gain insight into the feasibility and effectiveness of MBSR on burnout, empathy, and (work-related) wellbeing in GPs.
A mixed methods pilot study, including a waiting list-controlled pre-/post-study and a qualitative study of the experiences of participating GPs in the Netherlands.
Participants were sent questionnaires assessing burnout, work engagement, empathy, and mindfulness skills, before and at the end of the MBSR training/waiting period. Qualitative data on how GPs experienced the training were collected during a plenary session and with evaluation forms at the end of the course.
Fifty Dutch GPs participated in this study. The MBSR group reported a greater decrease in depersonalisation than the control group (adjusted difference -1.42, 95% confidence interval CI = -2.72 to -0.21, P = 0.03). Dedication increased more significantly in the MBSR group than in the control group (adjusted difference 2.17, 95% CI = 0.51 to 3.83, P = 0.01). Mindfulness skills increased significantly in the MBSR group compared with the control group (adjusted difference 6.90, 95% CI = 1.42 to 12.37, P = 0.01). There was no significant change in empathy. The qualitative data indicated that the MBSR course increased their wellbeing and compassion towards themselves and others, including their patients.
The study shows that MBSR for GPs is feasible and might result in fewer burnout symptoms and increased work engagement and wellbeing. However, an adequately powered randomised controlled trial is needed to confirm the study's findings.
Prospective study with 6 weeks of follow-up.
To examine the predictors of outcome for patients with (sub)acute low back pain (LBP) receiving usual care (UC) or a minimal intervention strategy (MIS) ...aimed at psychosocial factors.
A randomized controlled trial in general practice showed no differences in average effect between UC and MIS.
Socio-demographic variables, characteristics of LBP, and psychosocial factors were included as potential predictors of outcome. The outcome clinically important improvement was defined as a reduction of at least 30% on functional disability plus patient perceived recovery. Logistic regression analyses were used to study the associations between predictors and outcome at 6 weeks follow-up.
In the UC group (n = 163), the multivariable model included a shorter duration of the LBP episode, few previous episodes, less pain catastrophizing, and good perceived general health. The area under the curve (AUC) of the model was 0.77 (95% confidence interval, 0.70-0.85). In the MIS group (n = 142), the multivariable model included less somatizing symptoms, more solicitous responses by an important other, lower perceived risk for chronic LBP, more fear avoidance beliefs, higher level of education, and shorter duration of the LBP episode. This AUC was 0.78 (95% confidence interval, 0.71-0.86).
As we found two different profiles, our approach may contribute to the important question: what intervention works for whom?
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