Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2014. / Background: Myofascial Pain and Dysfunction (MPD) is a diagnosis commonly encountered by practitioners, hence, there are several treatment approaches employed by various practicing physicians. Practitioners are required to perform evidence-based protocols on patients; however, such intervention becomes increasingly difficult with the increasing volume of evidence available with regards to treatment of MPD. A systematic review provides a well-structured, critical analysis of the available protocols, and as such, provides practitioners with an evidence-based summary of the available modalities and the effectiveness of these modalities. Thus, the aim of the study was to systematically review and evaluate the literature to determine the effects of various non-invasive modalities on MPD. Objectives: Studies investigating various non-invasive modalities were identified, evaluated against the inclusion criteria and then reviewed against PEDro criteria to present current available evidence regarding their effectiveness as a source of treatment for MPD. Methods: A literature search was conducted, based on key terms including: active and latent myofascial trigger points, manual therapy, manipulation, acupressure, massage, muscle stretching, ultrasound, transcutaneous electric nerve stimulation, electric stimulation therapy, magnetic field therapy, and exercise therapy. Databases searched were: PubMed, EBSCOhost, Medline, CINAL, Proquest, Health Source, Sport Discus, Science Direct, Springer Link, Google Scholar and Summons. The articles were screened according to inclusion and exclusion criteria, after which a secondary hand and reference searches were performed. Thereafter, the articles were reviewed by four independent reviewers and the researcher. The PEDro Scale was used to determine methodological rigor of the included studies. The results were then analysed and ranked. Results: Following the screening process during data collection for this study, a total of 25 studies were identified and included. The review and ranking of these studies revealed a moderate level of evidence present for the effectiveness of Topical Agents. A limited level of evidence was noted for TENS, Ischemic Compression, Ultrasound, Laser and Other Modalities. Approximately 25% of the reviewed studies involved combination therapies; hence their outcomes cannot be applied to the effectiveness of individual modalities. Conclusion: Upon comparison of the quality of evidence available for the various types of modalities present for the treatment of MPD, it was noted that Topical Agents were supported by a stronger level of evidence than TENS, Ischeamic Compression, Ultrasound, Laser and Other Modalities. However, due to a lack of strong overall evidence for any of these modalities it has been concluded that more research is required to establish which modality is in fact the most effective.

Aim of the study is to explore the role caring practices within the nurse-patient relationship, in facilitating effective chronic pain management in the primary health care context. Objectives are to analyse the current caring practices within the nurse-patient relationship during the management of patients with chronic pain within primary health care services; explore the challenges experienced by nurses in primary health care services when managing patients with chronic pain; observe the caring practices within the nurse patient interaction for the patients suffering from chronic pain within the Primary health care setting and explain the nurses‟ caring practices when managing their chronic pain in the primary health care setting. Method The research design for this study is sequential, explanatory and mixed method, which is more appropriate due to the complexity of the phenomenon under study. Findings: Although the survey measured the caring practices subjectively which other studies had done consistently, generally nurses associated caring as their core function within the health profession. Nurses do not actively involve the patients in the development of a treatment plan and as a result the caring behaviours that are intended to benefit the patients are not realised and, thus patients report nurses as not being caring. The results indicated that lack of an inclusive treatment plan, which can only be discovered through the development of the therapeutic NPR, is not given priority in the management of patients with chronic pain Conclusions: Caring should not be seen as concrete execution of the set of activities towards the patient but rather as a joint venture between the nurse and the patient. The strength of the model developed in this study is the identification of the nurses‟ internal readiness to create a caring environment by experiencing the love, faith and hope before engaging with the patient. / Health Studies

Indiana University-Purdue University Indianapolis (IUPUI) / The presence of a chronic pain condition can have a profound impact on one’s self-concept. Some individuals may have had to make major lifestyle changes. As a result, some people may start to define themselves in terms of their pain, such that their self-schema and pain-schemas become intertwined in a process termed schema-enmeshment. It is thought that schema-enmeshment is related to psychological distress making it a prime target for intervention. Little research has been conducted on interventions to reduce schema-enmeshment. Acceptance-based interventions may be especially appropriate in reducing schema-enmeshment or the connection between self and illness symptoms as these interventions tend to emphasize learning to live with pain and other symptoms and to work toward important life goals rather than continually fighting against the condition and allowing it to control their life. This study is a randomized trial comparing Acceptance and Commitment Therapy (ACT) to education about pain management in a sample of women with Fibromyalgia Syndrome (FMS). The primary aim of this study was to assess the efficacy of ACT in reducing schema-enmeshment between self and pain, as well as enmeshment between self and other symptoms and FMS as a whole. In addition, this study also explored the role of pain acceptance, specifically activity engagement as a mediator of the relationship between treatment group membership and changes in schema-enmeshment. The data was analyzed as an intent-to-treat analysis using the “last measure carried forward” method. Results indicated that the ACT group reported statistically significant differences in self schema-enmeshment with FMS, fatigue, and cognitive symptoms, but not with pain, following the intervention, compared to the educational control group. In each of these cases, the ACT group experienced greater reductions in schema-enmeshment compared to the education group. Interestingly, no statistically significant differences were observed for schema-enmeshment with pain. Statistically significant group differences were also observed for acceptance of pain following the intervention. Finally, a mediational model in which changes in activity engagement (a form of pain acceptance) served as the mediator of the relationship between treatment group and changes in schema-enmeshment with FMS was tested. The model was tested using a bootstrapping method, and results revealed a trend toward a significant indirect effect of changes in activity engagement leading to changes in schema-enmeshment with FMS. Taken together, the results of this study indicate that ACT may be a promising intervention for targeting maladaptive beliefs about the self in relation to illness, especially schema-enmeshment of self with illness and illness symptoms. Additionally, there is evidence that ACT may target key constructs such as activity engagement, which may be related to other cognitive and behavioral changes. Future directions for research and clinical practice related to ACT as an intervention for FMS are discussed in depth.

Indiana University-Purdue University Indianapolis (IUPUI) / While the majority of chronic pain patients report receiving inadequate care, there is evidence that female and Black patients receive less analgesic medications and treatment for their chronic pain compared to male and White patients, respectively. While treatment disparities have been evidenced in the literature, there is little understanding of provider-factors, such as their decision-making awareness and attitudes, which may contribute to the differences in treatment. This investigation employed quantitative and qualitative procedures to examine the relationship between patient demographics and chronic pain treatment variability, providers’ awareness of these non-medical influences on their decisions, and the extent to which providers’ gender and racial attitudes associate with their treatment decisions. Twenty healthcare trainees made pain treatment decisions (opioid, antidepressant, physical therapy, pain specialty referral) for 16 computer-simulated patients presenting with chronic low back pain; patient sex and race were manipulated across vignettes. Participants then selected among 9 factors, including patient demographics, to indicate which factors influenced their treatment decisions for the simulated patients and completed gender and racial attitude measures. After online study completion, follow-up semi-structured interviews were conducted to discuss the medical/non-medical factors that influence trainees’ clinical treatment decisions. Quantitative analysis indicated that 5%-25% of trainees were actually influenced (p<0.10) by patient sex and race in their treatments, and on the whole, trainees gave higher antidepressant ratings to White than Black patients (p<.05). Fifty-five percent demonstrated concordance, or awareness, between their actual and reported use of patient demographics. Follow-up McNemar’s test indicated trainees were generally aware of the influence of demographics on their decisions. Overall, gender and racial attitudes did not associate with trainees’ treatment decisions, except trainees’ complementary stereotypes about Black individuals were positively associated with their opioid decisions for White patients. During qualitative interviews, aware and unaware trainees discussed similar themes related to sex and racial/ethnic differences in pain presentation and tailoring treatments. We found that (1) a subset of trainees were influenced by patient sex and race when making chronic pain treatment decisions, (2) trainees were generally aware of the influence of patient demographics, and (3) trainees discussed differences in pain presentation based on patients’ sex and ethnic origin. These findings suggest trainees’ are influenced by patient demographics and hold stereotypes about patient populations, which may play a role in their decision-making.