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By Y. Chenor. Angelo State University.

Drawing on published literature and the experiences observed in the AMEDD demonstrations 1000 mg valtrex for sale, we identified six critical success factors that strongly influence how successful an MTF will be in integrating new practices into its clinical and administrative processes (Chodoff and Crowley valtrex 500 mg with amex, 1995) cheap 500mg valtrex overnight delivery. In the evaluation purchase 500mg valtrex, we assessed the performance of demonstration participants on these factors: (1) visible and consis- tent commitment by the MEDCOM leadership at all levels discount 1000 mg valtrex fast delivery, (2) ongo- ing monitoring and reporting of implementation progress in carrying out an action plan, (3) implementation guidance to the MTFs by MEDCOM, (4) identification of an effective physician guideline champion at each MTF, (5) dedicated time and adequate resources for the guideline champions, and (6) rapid integration of new prac- tices into a clinic’s normal procedures. The DoD/VA low back pain guideline was introduced in the Great Plains Region in November 1998 at the demonstration kickoff con- ference. The asthma guideline demonstration began in the Southeast Region in August 1999, and the diabetes guideline was introduced in the Western Region in December 1999. The guideline implementa- tion process used in the demonstration consisted of (1) the practice guideline and metrics, (2) a guideline toolkit of materials to support the MTFs’ implementation activities, (3) a kickoff planning confer- ence at which demonstration MTF teams developed their implemen- xviii Evaluation of the Low Back Pain Practice Guideline Implementation tation strategies and action plans, (4) MTF implementation activities following the kickoff conference to carry out the teams’ action plans, (5) information exchange among the teams to share experiences and build on each other’s successes, and (6) monitoring of implementa- tion progress by both MEDCOM and the participating MTFs. Each demonstration was followed by Army-wide implementation of its guideline, beginning with the low back pain guideline in spring 2000. The Demonstration Sites Each demonstration was located in a different region to maximize the training and exposure of MTF personnel to the practice guide- lines and implementation methods in preparation for systemwide implementation. The low back pain guideline demonstration was conducted with MTFs in the Army Great Plains Region. This region was selected for the first demonstration because it contains a large number and diversity of Army posts, MTFs, and populations served. A large number of all Army active duty personnel are stationed at Great Plains Region posts, and many military retirees and their de- pendents live within their catchment areas. Four MTFs in the Great Plains Region served as demonstration sites: William Beaumont Army Medical Center at Ft. The four MTFs represented diverse patient populations, facility sizes, and service mixes. At the time of the demonstration, two MTFs were sites for the DoD-Medicare Subvention Demonstration, in which the MTFs enrolled and provided services to Medicare-eligible DoD beneficia- ries, and they also were chiropractic demonstration sites. Chiro- practic services historically had not been available in military facili- ties, so the other two MTFs did not have these services. The chiro- practic demonstration was intended to generate information for use by DoD in deciding whether to provide chiropractic services in its health facilities. Summary xix THE RAND EVALUATION The evaluation of the demonstration consisted of a process evalua- tion and an analysis of the effects of the guideline on service utiliza- tion. The specific methods and data used in the evaluation are de- scribed in Chapter Two and Appendix A. In the process evaluation, the RAND team used a participant- observer approach to learn from and about the MTFs’ experiences, to provide feedback, and to facilitate shared learning among the MTFs throughout the demonstration and evaluation process. The purposes of the process evaluation were to (1) document the actions and ex- periences of the participating MTFs and assess performance relative to each of the six critical success factors; (2) identify areas where AMEDD policies, systems, and processes can be strengthened; and (3) assess the degree to which MTFs can build on their experiences with the demonstration to implement additional DoD/VA guidelines. In the process evaluation, we collected information from the partici- pating MTFs through a series of site visits, monthly progress reports prepared by the MTFs, and questionnaires completed by individual participants. Three site visits were conducted at each demonstration site: an introductory visit before the kickoff conference, a post- implementation visit in June 1999 at three to four months after the MTFs began implementing the guideline, and a second post- implementation visit in February 2000 (at month nine or ten of implementation). During each post-implementation site visit, RAND staff interviewed the MTF’s implementation team and others involved in changing practices in response to the new guideline. Summary reports of the results of the final round of site visits for the four participating MTFs are presented in Appendix B. The purposes of the analysis of the effects of guideline implementa- tion were to (1) document the extent to which intended actions were actually implemented by the MTFs; (2) monitor short-term effects on service delivery methods and activity, and where feasible, on client outcomes; and (3) develop metrics and measurement methods that can be adopted by the MTFs and MEDCOM for routine monitoring of progress. An interrupted time series comparison-group design was used to as- sess the effects of the low back pain guideline demonstration. Quar- xx Evaluation of the Low Back Pain Practice Guideline Implementation terly administrative data on service utilization and medication pre- scriptions were collected for low back pain patients served by the demonstration and comparison (control) sites, which provided trend information both before and after introduction of the guideline in the Great Plains Region. The comparison group allowed us to control for temporal trends that might account for changes in the indicators. The measures were appropriate choices for this demonstration because most of the participating MTFs focused their implementation actions on service delivery for acute low back pain (rather than chronic low back pain). The patient population for this study was limited to active duty Army personnel who received care for acute low back pain at one of the demonstration or comparison sites during the time period of the study. This design was selected because we could not obtain com- plete pharmaceutical data for all patients using these MTFs. The pharmacy data constraint was important because use of pain medi- cations is a major aspect of care for acute low back pain patients, and one-half of the indicators selected for the study are measures of pain medication use.

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Dr Douglas Justins MB BS FRCA Consultant in Pain Management and Anaesthesia GENERAL ABBREVIATIONS AA Acupuncture analgesia ACR American College of Rheumatology AHCPR US Agency for Health Care Policy and Research BMA British Medical Association BPI Brief pain inventory CBT Cognitive behavioural therapy CEBM Centre for evidence-based medicine (Oxford) CER Control event rate CNS Central nervous system CNCP Chronic non-cancer pain COX Cyclo-oxygenase – there are at least two different isoforms CRF Case report form CRPS Complex regional pain syndrome DCN Dorsal column nuclei DDS Descriptor differential scales DNIC Diffuse noxious inhibitor control DREZ Dorsal root entry zone DSM Diagnostic and statistical manual for mental disorders EA Electroacupuncture EER Experimental event rate EMG Electromyogram FMS Fibromyalgia syndrome GP General practitioner HIV Human immunodeficiency virus IASP International Association for the Study of Pain ICU Intensive care unit IV Intravenous JCAHO Joint Commission on Accreditation of Healthcare Organisations LA Local anaesthetic MA Manual acupuncture MAOI Monoamine oxidase inhibitor MDT Multidisciplinary teams MPQ McGill pain questionnaire MRI Magnetic resonance imaging NCHSPCS National Council for Hospice and Specialist Palliative Care Services NHMRC Australian National Health and Medical Research Council NHS National Health Service NHSE National Health Service Executive NICE National Institute for Clinical Excellence NNT Number needed to treat NNH Number needed to harm NSAID Non-steroidal anti-inflammatory drug NCA Nurse controlled analgesia NO Nitric oxide NRS Numerical rating scale OR Odds ratio xviii GENERAL ABBREVIATIONS PCA Patient controlled analgesia PDN Peripheral diabetic neuropathy PET Positron emission tomography PG Prostaglandin PHN Post-herpetic neuralgia PMP Pain management programme RCS Royal College of Surgeons RCT Randomised controlled trial RSD Reflex sympathetic dystrophy SC Spinal cord SIP Sympathetic independent pain SMP Sympathetic mediated pain SN Solitary nucleus SOP Special operating procedure SR Systematic review SSRI Selective serotonin reuptake inhibitors TCA Tricyclic agents (note: two uses – see below) TCA Traditional Chinese acupuncture (note: two uses – see above) TENS Transcutaneous electrical nerve stimulation TGN Trigeminal neuralgia TP Trigger point TeP Tender point VAS Visual analogue scale VRS Verbal rating scale WHO World Health Organisation BASIC SCIENCE ABBREVIATIONS 5-HT 5-hydroxytryptamine (serotonin) 9-THC 9-tetrahydrocannabinol 2 Adenosine type two receptors AA Arachidonic acid AC Adenylyl cyclase AEA Anandamide/arachidonylethanolamide AMPA Alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid ASIC Acid-sensing ion channels (numbered 1–3) – a family of pH sensors ATP Adenosine triphosphate BDNF Brain derived neurotrophic factor BK Bradykinin – peptide known to be algogenic Ca2+ Calcium ions cAMP Cyclic adenosine monophosphate – important intracellular messenger CB1 Cannabinoid receptor type 1 CB2 Cannabinoid receptor type 2 cGMP Cyclic guanosine monophosphate – important intracellular messenger CGRP Calcitonin gene related peptide COX Cyclo-oxygenase – there are at least two different isoforms CRPS Complex regional pain syndrome DAG Diacyl glycerol – important intracellular messenger DCN Dorsal column nucleus DH Dorsal horn DOP Delta opioid receptor DRG Dorsal root ganglion EP1-4 Prostanoid receptor – a family GABA Gamma amino butyric acid GC Guanylyl cyclase GDP Guanosine diphosphate GDNF Glial derived nerve growth factor Gs G-protein – through which many receptors link to intracellular events GTP Guanosine triphosphate H+ Hydrogen ions – important inflammatory mediator H1 Histamine receptor type 1 H2 Histamine receptor type 2 IL-1 Interleukin 1 IL-2 Interleukin 2 IP3 Inositol triphosphate – important intracellular messenger Ins(1 valtrex 1000 mg sale,4 valtrex 500 mg low cost,5)P3 Inositol (1 valtrex 500mg amex,4 discount 1000mg valtrex otc,5) triphosphate IUPHAR International Union of Pharmacology KOP Kappa opioid receptor LA Local anaesthetic LOX Lipoxygenase LTB4 Leucotriene B4 MOP Mu opioid receptor NE Norepinephrine/Noradrenaline NEP Neutral endopeptidase xx BASIC SCIENCE ABBREVIATIONS NGF Nerve growth factor NK1 Neurokinin 1 NK2 Neurokinin 2 – receptor for neurokinin A NK3 Neurokinin 3 – receptor for neurokinin B NKA Neurokinin A – peptide related to substance P NKB Neurokinin B – peptide related to substance P NMDA N-methyl-D-aspartate NO Nitric oxide N/OFQ Nociceptin – also known as orphanin FQ NOP Nociceptin receptor NOS Nitric oxide synthase – enzyme that produces NO NR1 Subunit of NMDA receptor – essential for activity NSAID Non-steroidal anti-inflammatory drug NT-3 Neurotrophic factor 3 NTF Neurotrophic factor P2X3 Purine channel – responds to the algogen ATP PAG Periaqueductal grey PEA Palmitoylethanolamide PET Positron emission tomography PGE2 Prostaglandin E2 – main pain producing prostanoid PLA2 Phospholipase A2 – important intracellular messenger PKA Protein kinase A – important intracellular messenger PKC Protein kinase C PLC Phospholipase C – important intracellular messenger PLA2 Phospholipase A2 PN3 Another name for SNS (also known as Nav 1 generic 500mg valtrex with amex. Jaggar A major barrier to appropriate pain management is a nociceptive pathway from: general misperception that pain and nociception are – Stimulus events to chemical tissue events. This encourages the belief – Chemical tissue and synaptic cleft events to that every individual will experience the same sensa- electrical events in neurones. This is analogous to – Electrical events in neurones to chemical events suggesting that all individuals will grow to the same at synapses. Electrical events are transmitted along neuronal pathways, while molecules in the synaptic cleft Nociception is the neural mechanism by which an transmit information from one cell surface to individual detects the presence of a potentially tissue- another. There is no implication of (or • Modulation: requirement for) awareness of this stimulus. The adjustment of events, by up- or downregula- Pain is ‘an unpleasant sensory and emotional experi- tion. This can occur at all levels of the nociceptive ence associated with actual or potential tissue damage, pathway, from tissue, through primary (1°) afferent or described in terms of such damage’. The nociceptive mechanism (prior to the perceptive The chapters that follow address the pathophysiolog- event) consists of a multitude of events as follows: ical events occurring along the ‘pain pathway’. It is • Transduction: important to recognise that all the anatomical struc- This is the conversion of one form of energy to tures and chemical compounds described are genet- another. Therefore, to suggest that all individuals Inevitable perception of ‘Hard-wired’ system of pain by the brain transmission via spinal cord Transduction from electrical to chemical energy and vice versa Noxious stimulus applied to peripheral tissue Transduction from ‘Hard-wired’ system of heat to electrical transmission via peripheral energy neurones Figure 1. For example, we would not suggest that eye colour is something over which people have total control – we Once electrical activity is generated within the 1° accept that this is genetically determined. Yet, we afferent neurone, information is transmitted to the suggest that an individual who is unfortunate enough dorsal horn of the spinal cord. Activity is induced in to suffer severe pain (perhaps consequent upon the the second-order neurone in a similar fashion. Quantal expression of particular populations of receptors release of neurotransmitters from the 1° afferent neu- responding to nociceptive chemicals) is somehow rone is dependent upon: (a) activity within the neurone, ‘over-reacting’ to a stimulus. Moreover, we under- (b) external events affecting alterations in neuronal stand that the presence of male pattern baldness activity, for example, inhibitory and excitatory inputs requires not only the presence of a gene, but also a upon pre-synaptic terminal. Activity in the second- particular hormonal environment (high testosterone order neurone is again dependent upon the balance of levels). These may arise from the particular stimulus may be perceived differently in 1° afferent neurone, inter-neurones or descending individuals with varying hormonal make-up? This is not to suggest that all pain is entirely genet- The majority of second-order nociceptive neurones ically determined, but rather it is not ‘all in the mind’ – within the spinal cord cross to the contralateral side, a phrase often used with negative connotations in where they synapse upon neurones in the antero-lateral regard to pain patients. Again modulation of transduction undoubtedly alter perceptions, but this should not events will occur, prior to transmission in spino-thalamic suggest any ‘unreality’. Similarly, prior experience of pain may While we have long considered neurological pathways facilitate activity, in particular neuronal pathways, to be hard wired, it is becoming increasingly clear that leading to a reduction in pain threshold at a later date. Indeed, the brain and spinal cord are able to learn and facilitate activity in commonly A variety of tissue-damaging stimuli leads to the pro- utilised pathways. Thus, we should chemical binding with receptors on 1° afferent neur- not be surprised that previous experiences can and ones. Inflammatory soup 1º Afferent neurone Rinhibit Rexcite Rsensitise Rinhibit Inhibitory neurone influence Transmission depends 1º Afferent neurone upon balance of inputs Peripheral Central (gate control) (descending control) Figure 1. OVERVIEW OF PAIN PATHWAYS 5 The genetic basis of pain (using human and animal The psychological processing and consequences are data to demonstrate the concepts) will be considered central to all our human experience. The challenge Chapters 2 and 3 on the peripheral and central mech- now is to unite psychological and chemical (and thus anisms of pain, you should remember that the chemi- genetic) events in an appropriate fashion when con- cals and structures described are genetically encoded, sidering the problems faced by patients in pain. Chapters 5–7 will deal in detail with the ways in which previous activity within the nociceptive pathways may alter current activity (and thus pain perception). Cafferty Overview Classification by size A-fibres Sensory systems are the nexus between the external world and the central nervous system (CNS). Afferent A-fibres are myelinated, have large cell body diameters neurones of the somatosensory system continuously and can be subdivided into three further groups: A -, ‘taste their environment’ (Koltzenburg, 1999). A -fibres innervate muscle spindles respond in a co-ordinated fashion, in order to instruct and Golgi tendon organs, and determine propriocep- an integrated efferent response, which will retain the tive function. A -fibres are low-threshold, cutaneous, homeostatic integrity of the organism and curtail any slowly or rapidly adapting mechanoreceptors and do not tissue-damaging stimuli.

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Someone said that every night when we go to sleep we all go quietly and safely insane because that’s when the remnants of childish buy discount valtrex 1000 mg online, primitive purchase valtrex 500mg mastercard, wild behavior that are a part of everyone’s emotional repertoire can show themselves without being monitored by the waking buy 1000mg valtrex, conscious mind 1000 mg valtrex sale. The unconscious is the repository of all of our feelings cheap 500mg valtrex otc, regardless of their social or personal acceptability. To know about the unconscious is extremely important, for what goes on down there may be responsible for those personality characteristics that drive us to behave as we do when we’re awake—and the unconscious is where TMS and other disorders like it originate. It is an interesting fact that the overwhelming majority of emotional and mental activity occurs below the level of consciousness. The human mind is something like an iceberg—the part that we are aware of, the conscious mind, represents a very small part of the total. It is in the subconscious mind that all of the 34 Healing Back Pain complicated processing goes on that allows us, for example, to generate written and oral language; to think, to reason, to remember; in short, to do most of the things that identify us as human beings. Our ability to make sense of the things we see, to recognize faces, and dozens of other mental activities we take for granted are the result of brain activity of which we are unaware. Feelings that remain there do so because they are repressed and it is these that are responsible for the sequence of events that causes TMS. Incidentally, one should make a distinction, as Freud did a long time ago, between mental items that are not conscious but which can be brought to consciousness with effort, like the things in our memories—Freud called that mental domain the preconscious— and things in the unconscious that are unavailable and cannot be recalled. To better understand how and why TMS gets started, it’s essential to look at some of these unconscious emotional processes. Low Self-Esteem I find it almost shocking to realize how common it is for people to have feeings of inferiority deep inside. There must be a cultural reason for this that is reflected in the way we are managed as children and, therefore, the way we develop. This is a subject that should be studied intensively and no doubt will be someday. These feelings of inferiority are deep and hidden but reveal themselves through our behavior. This was beautifully illustrated many years ago when a self-proclaimed “tough guy” came under my care for crippling back pain. The staff reported The Psychology of TMS 35 that he was constantly bragging about his prowess in hand-to-hand combat, in financial matters and with women. Emotionally, he was a very little boy trying desperately to prove to himself and the world how tough he was. It is likely that for most of us the compulsive need to do well, succeed and achieve is a reflection of deep-seated feelings of inferiority. Wherever it comes from, the need to accomplish or live up to some ideal role, such as being the best parent, student or worker, is very common in people who get TMS. A typical example was a patient who through compulsive hard work established a very successful business and became the patriarch and benefactor of his large family. Throughout his entire adult life he had low back pain, which resisted all attempts at treatment. By the time I saw him the pain patterns were deeply ingrained and part of his everyday life. He understood the concept of tension-induced pain but was unable to erase the patterns of a lifetime. He felt that he was too old to engage in psychotherapy, which is often required for patients like this. The primary benefit he derived from treatment was the reassurance that there was nothing structurally wrong with his back. Another patient was a young man in his twenties who had his first child shortly before he opened a new branch of the family business. The simultaneous imposition of these new responsibilities in this very conscientious young man induced severe low back pain due to TMS. As soon as he became aware that the source of his symptoms was inner tension, the pain disappeared. What these two people had in common was a great sense of responsibility and a strong inner drive to succeed in both business and family matters. Such people don’t need to be monitored; they are self-motivated, self-disciplined, their own severest critics. People who get TMS are often intensely competitive, success 36 Healing Back Pain oriented, achieving and usually very accomplished.

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