The Correlation between Pharmacological and Non-pharmacological Treatment - Research Proposal Example

 Research Proposal - The Correlation between Pharmacological and Non-pharmacological Treatment in Managing Chronic Pain with the Musculoskeletal Physiotherapists-Patient Relationship - Table of Contents I. Title ……….…………………..…………………………………….. 4 II. Purpose of the Research Study …………………………………. 4 III. Problem Statement ……………………………………………….. 4 IV. Significance of the Problem …………………………………….. 4 V. Definition of Terms …………………………………………..…… 5 VI. Hypothesis / Research Question ………………………………... 6 VII. Literature Review ………………………………………………….. 6 a. A Brief Introduction about Musculoskeletal Pain ….. 6 b. Negative Impact of Musculoskeletal Pain on Elderly Patient …………………………………………….. 8 c. Factors that Trigger Musculoskeletal Pain ………….. 9 d. Education and Trainings of Health Care Professionals on Musculoskeletal Disorders ………. 9 e. Existing Pharmacological Treatment for Musculoskeletal Pain ……………………………………. 10 e. Existing Non-Pharmacological Treatment for Musculoskeletal Pain ……………………………………. 12 f. The Impact of Physiotherapist-Patient Relationship on Musculoskeletal Pain ……………….. 12 VIII. Ethical Issues Involved ……………………………………………. 13 IX. Methodology ……………………………………………………….. 14 a. Proposed Research Design ……………………………. 14 b. Sample Data ………………………………………………. 15 c. Data Collection Method / Instrument(s) ………………. 15 d. Data Analysis ……………………………………………... 18 X. Research Schedule ……………………………………………….. 18 XI. Cost / Feasibility Analysis ………………………………………… 19 XI. Assumptions and Limitations ……………………………………. 19 Appendix I –Time Table for the Completion of the Study …………………. 21 References ……………………………………………………………… 22 - 29 Title “The Correlation between Pharmacological and Non-pharmacological Treatment in Managing Chronic Pain with the Musculoskeletal Physiotherapists-Patient Relationship” Purpose of the Research Study For this study, the purpose will be to determine the most effective chronic pain management strategies perceived by elderly patients with musculoskeletal pain. This information may be used in developing a reliable musculoskeletal education programs in line with the purpose of improving the pain management in different health care settings. Problem Statement Is the relationship between musculoskeletal physiotherapists and patients the most effective pain management strategy when it comes to dealing with elderly patients who are diagnosed with chronic musculoskeletal pain disorder? Significance of the Problem Chronic pain among the elderly patients could affect five dimensions in the life of the patient(s) including: physical, psychological, emotional, social, and spiritual. In the long run, chronic pain affects the physical functioning of the elderly patients particularly their ability to perform activities of daily living (ADLs) – an important form of exercise among the patients (Dewar, 2006); health and appetite (Bosley et al., 2004); and their sleep patterns (Ross & Crook, 1998). Since chronic pain is considered as the major contributor of degraded quality life, reduced well-being, and physical disability among the elderly patients (Standard of Care for People with Regional Musculoskeletal Pain, 2007), determining the best method on how to alleviate chronic musculoskeletal pain among the older patients becomes very important in the profession of the physiotherapists. In line with finding the best method in managing musculoskeletal pain disorder, the problem statement of the research study will give way for the researcher(s) to express and remind the musculoskeletal physiotherapists that building a good interpersonal relationship with the patients will help in managing the chronic pain among the elderly patients. Definition of Terms Chronic Pain – pain with unknown cause that could last more than a period of six months. Fibromyalgia – a condition of pain in the muscles and fibers. (Armand & Merek, 2008) Musculoskeletal Pain – pain that occurs within the musculoskeletal system which consists of the bones, muscles, ligaments, tendons and fascia. (Asher, 2008) Non-pharmacologic Pain Treatment – pain treatment options that do not use drugs such as relaxation techniques like yoga and meditation used to decrease muscle tension and reduce stress; ‘electrophysical agents’ such as cryotherapy, electrotherapy, heat therapy and iontophoresis; or manual therapy techniques like soft tissue massage and joint mobilization / manipulation. Perceived Effectiveness – refers to the personal or voluntary acceptance of the patients with regards to the effectiveness of a treatment method. Pharmacologic Pain Treatment – refers to a variety of different compounds such as opioids and psychotropic medications like anti-depressants and anti-convulsivants. Hypothesis / Research Question For the purpose of this study, the research question will be stated as follows: (1) What is the best chronic pain management interventions perceived as the most effective by patients with musculoskeletal pain disorder? Is it the pharmacological treatment, non-pharmacological treatment such as the relationship between the musculoskeletal physiotherapists and the patients or both? Literature Review A Brief Introduction about Musculoskeletal Pain Musculoskeletal disorders are a common cause of long-term disability in the United Kingdom (Martin et al., 1998) wherein almost 15% of these patients are being taken care of by the general practitioners in the primary and/or secondary health care service (Roberts et al., 2002) or in an acute rheumatology service and other clinical units (Smith et al., 1996), a group of orthopaedic referrals that are professionally handled by trained physiotherapists (Daker-White et al., 1999), and in the secondary care rheumatology clinics wherein patients are handled by the trained nurses (Hill, 1997). Despite the huge number of individuals who are experiencing musculoskeletal pain disorders, not all of them consult for a medical service. (Urwin et al., 1998) Musculoskeletal pain exists not only among the elderly patients but also among the mid- or late adolescents patients. As much as 53% of the young adults have experienced musculoskeletal pain at some point in their lives. (Qvindesland & Jonsson, 1999) In UK alone, roughly four and a half million people whose age is more than 50 years old suffers from a severe knee pain. (Underwood, 2004) Based on a statistical forecasted study, the population of people more than the age of 40 is expected to increase up to 25 million by the end of year 2020. (Ageing Population Panel, 1999) The duration wherein musculoskeletal pain occurs can either be short- or long-term. Such pain can be felt by anyone particularly in body regions such as the wrist, arm or knee. Based on self-reported cases, between 10 – 30% of individuals who experience musculoskeletal pain occurs on the shoulders which usually last for more than a week up to one month; roughly 5 – 10% of these cases are highly associated with elbow pain; and 5 – 15% experience hand-related pains. (Standard of Care for People with Regional Musculoskeletal Pain, 2007) On the other hand, 15% of them suffer from disabling foot and ankle pain. Some of the most commonly known chronic musculoskeletal pain is the fibromyalgia, carpal and myofascial syndrome. In most cases, musculoskeletal disorders are highly associated with rheumatism caused by the inflammation of the connective tissue or the muscles. (Hosie, 2000) Studies were conducted in the past revealing that the location of musculoskeletal pain is often reported to be associated with 30% lower limb pain (Shrier et al., 2001) followed by 28% neck or upper limb pain (Ehrmann Feldman et al., 2002). In line with this matter, the research study conducted by El-Metwally et al. (2007) concluded that lower limb is the most common site of traumatic pain where as neck pain is the most common site of a non-traumatic pain. (El-Metwally et al., 2007) Considering the negative implications of musculoskeletal pain on people, each individual should consider the primary care for musculoskeletal pain as an opportunity to reach for a timely and appropriate care and management of pain and disability. (Waddell & Burton, 2004; Hagen et al., 1997) Negative Impact of Musculoskeletal Pain on Elderly Patients Even though the risk factors associated with musculoskeletal pain is not clear, it is a fact that it could negatively affect the physical, social, emotional, and the overall well-being of a person (Flato et al., 1997; Reid et al., 1997) makes musculoskeletal disorders a serious health problem. Based on several reported cases, the most important risks of musculoskeletal pain is related to the high level of psychological distress caused by the inconvenience of their inability to move by themselves or the lack of autonomy when working or doing simple things such as the activities of daily living which directly affects the mood swings and personality disorders among the patients. (Nahit et al., 2003; Fredriksson et al., 1999; Lundberg, 1999; Jamison, 1996) Several studies have been conducted with regards to the existence and treatment of lower back pain especially among the older individuals. (Braverman, 2003; van den Hout et al., 2003) A chronic low back pain among the elderly patients should be taken seriously by musculoskeletal physiotherapists since it could affect the patients’ ability to sit, stand and lift aside from the fact that it could result to a long-term sleeping disturbance. (Hagg et al., 2003) In other words, musculoskeletal pain that occurs on lower limb is a more serious problem than that of the upper limbs since it could hinder a person’s mobility causing them a decrease in their level of self-confidence. Factors that Triggers Musculoskeletal Pain The lack of proper education on the primary causes of musculoskeletal pain is the one of the most common factors that could lead to such health deteriorating situation. In line with the musculoskeletal pain in the lower limb, the clinical study conducted by Hong et al. (2005), the authors suggest that working women should avoid wearing high-heeled shoes in order to prevent foot and ankle disorders that could lead to excessive pain in the long-run. Instead, they should wear shoe insert in order to enhance the comfort of their feet while at work. Aside from external factors, the study of Delaney et al. (2002) explains that a sudden increase of heart rate could contribute to excessive muscle tension that causes chronic muscle pain to anyone. Another factor that could cause muscle pain is excessive stress related to over work which is most commonly connected with fibromyalgia and chronic fatigue syndrome. (van Houdenhove et al., 2001) The main cause of neuromuscular pain in fibromyalgia is the shortening of the muscles or spasm due to the lack of sufficient blood supply in the intramuscular nerves causing the tendons, bones, and joint to produce tractions. (Katz et al., 2007) In most cases, this type of pain occurs either on the neck area and the upper limb or both. The neuropathic disorders such as the complex regional pain syndromes (CRPS) or reflex sympathetic dystrophy could also lead excessive pain. (Pham & Lafforgue, 2003) Education and Trainings of Health Care Professionals on Musculoskeletal Disorders There is a big difference between the health care approach of a general practitioner and a certified musculoskeletal physiologist when dealing with patients who are diagnosed with musculoskeletal disorders; particularly those who are suffering from chronic pain. Most of the general practitioners who handle patients with musculoskeletal disorder did not have adequate education and trainings with regards to the subject matter. In fact, many of the junior medical staff acquires less knowledge on musculoskeletal disorders (Doherty et al., 1990) as compared with musculoskeletal physiologists. The main reason that causes the lack of knowledge on musculoskeletal disorders among the general practitioners is due to inadequacy in the formal teaching given to them at the medical schools or in a vocational training centre (Lanyon et al., 1995) particularly when it comes to clinical skills (Jones et al., 1992). In the end, most of the general practitioners handle the patients with suboptimal care by not referring enough patients to seek the guidance of a professional physiotherapist.1 (van Tulder et al., 1998; Davis & Suarez-Almazor, 1995) In order to increase the knowledge of the general practitioners when it comes to the proper handling of musculoskeletal disorders, most of the consultant rheumatologists end up being involved in providing effective trainings for them. (Badley & Lee, 1987) Existing Pharmacological Treatment for Musculoskeletal Pain Some of the general practitioners prescribe non-steroidal anti-inflammatory drugs (NSAIDS) to 22% of the patients with musculoskeletal disorder. (van Tulder et al., 1998) Basically, the lack of proper education and trainings among the general practitioners on musculoskeletal disorders often makes them depend too much on prescribing NSAIDS and / or the use of intra- or peri-articular steroid injections to patients even at the early stage of rheumatoid arthritis. (Irvine et al., 1995) In line with the use of NSAIDS on musculoskeletal pain, there is inadequate evidences that could prove that the oral intake of NSAIDS such paracetamol could reduce the symptoms of low back pain. (Dieppe et al., 2000) Not much evidence could prove that managing a low back pain by administering corticosteroid injections to the patients is the best therapy to ease the pain. Although the healing effect could last only between two to three months, a study shows that the use of corticosteroid injections could be effective in treating a painful stiff shoulder better than the other treatment methods used in physiotherapy. (van der Windt et al., 1998) Several past studies show that administering a high dose of corticosteroids to patients could cause osteoporosis in the trabecular bone which is found in the lumbar spine (Rickers et al., 1984) whereas a low dose of corticosteroids could trigger a loss of bone mineral density in the lumbar spine (Buckley et al., 1996a; Laan et al., 1993; Hall et al., 1993). In order to avoid the vertebral fracture among patients who are receiving continuous therapy on low-dose corticosteroids, Buckley et al. (1996b) highly recommend add the oral intake of calcium and vitamin D3 in the patients’ diet. When treating a complex regional pain syndrome (CRPS) or a reflex sympathetic dystrophy, the best treatment method to alleviate the pain is a combination of physical therapy and oral treatment such as a sympathetic nerve blocks ‘tricyclic anti-depressants’ (TCSa), opiates, anticonvulsives, and psychological treatment. (Ribbers et al., 2003) Existing Non-Pharmacological Treatment for Musculoskeletal Pain A non-pharmacological treatment such as a body massage could help the muscles relax due to the decrease in the blood pressure. Particularly the study of Delaney et al. (2002) reveals the fact that giving a myofascial trigger-point massage therapy could significantly decrease the systolic and diastolic blood pressure and eventually improve the person’s heart rate. (Delaney et al., 2002) In line with giving a body massage therapy to the patients with musculoskeletal disorders, the emotional state and muscle tension of the patients could significantly improve. In order to prevent chronic pain and sufferings that are related to fibromyalgia and chronic fatigue syndrome, the patient should be able to adjust his/her lifestyle by going through a psychological counselling. (van Houdenhove et al., 2001) Since the pain of fibromyalgia occurs in the muscles due to extreme exertion and anaerobic metabolism. Therefore, there is a need to normalize the vasomotor by increasing the muscle perfusion and allows the muscle to relax by giving the patient a massage therapy. Another non-pharmacological way of treating fibromyalgia is the use of electrical stimulation which is applied to the neuromuscular junctions in order to reduce the muscle contractions. (Katz et al., 2007) With regards to pain related to foot and ankle, it is necessary to consider the characteristics of footwear in relation to foot pain problems among the elderly individuals. (Menz & Morris, 2005) Basically, wearing more comfortable shoes could lessen the pain on the feet and ankle. The Impact of Physiotherapist-Patient Relationship on Musculoskeletal Pain A good relationship between the physiotherapist and the patients could improve and lessen the occurrence of musculoskeletal pain. A recent study conducted by Burns et al. (2006) shows that patients who are constantly angry could lead to muscle tension which triggers the occurrence of a chronic low back pain. When a person is angry, the electromyographic tension which is located in the lumbar paraspinal muscles increases due to the sudden increase in the systolic blood pressure. In line with this matter, the authors concluded that anybody who suppresses their anger is more likely to experience pain that is associated with a high level of muscle tension. Another significant reason behind the need to promote a good relationship between physiotherapist and the patients is due to the fact that a low back disability in patients is highly associated with an emotional distress. (Brage et al., 2007) Ethical Issues Involved When conducting a primary research, it is ethical to obtain permission from the person-in-charge of the nursing home and each of the individuals who will participate in the research survey process. (Driscoll, 2006) In line with the interview process, the type of questions asked should not cause any physical or emotional harm on the part of the respondents. In case the respondents prefer not to be known to the public, the researcher should respect the respondents’ decision. When it comes to evaluating the survey results, it is ethical for evaluators to serve not only the interest of the researcher but of a larger society wherein the interest of the respondents are carefully taken into consideration. (American Evaluation Association, 1994) The researcher should always give a fair consideration over the researcher’s personal opinion and the opinion of the respondents. This way, the evaluators could avoid having a bias conclusion. Methodology Proposed Research Design A descriptive correlational design will be used in measuring the effectiveness of the different pain management practices and methods that has been provided to the elderly patients who have been confined in two separate nursing homes. In the process, the researcher will obtain a permit to conduct the study from the person-in-charge in each of the selected nursing home. As part of the study, the researcher will personally interview each of the nurses in order to determine who among the elderly patients have chronic musculoskeletal pain from those who do not have. The researcher will also list down the type of treatment approaches given to each of the elderly patient who have been experiencing a musculoskeletal pain for more than a period of six months. Based on each of the interview results, the researcher will design a survey questionnaire to be used upon conducting a one-on-one interview with the selected elderly patients. Aside from the instances wherein the elderly patients has experienced the worst chronic musculoskeletal pain, the respondents will also be asked to rate the pain on a numeric scale of 1 – 10. Using the same numeric scale, the qualified elderly patients will be requested to rate the degree of pain after the musculoskeletal physiotherapist and nurses has delivered the following treatment/medication: (1) a medical intervention particularly the use of pharmacological treatment such as opioids and psychotropic medications like anti-depressants and anti-convulsivants; (2) a non-pharmacological treatment such as ‘electrophysical agents’ like cryotherapy, electrotherapy, heat therapy or iontophoresis; (3) a manual therapy techniques like soft tissue massage and joint mobilization / manipulation; and (4) a good nurse-patient or musculoskeletal physiotherapists and patient relationship and how it affects their activities of daily living. Eventually, the researcher will use a descriptive statistics to describe the sample gathered for this study. After analyzing the final correlational statistical results, the researcher will make a conclusion as to whether or not the respondents consider the relationship between musculoskeletal physiotherapists and patients to be the most effective pain management strategy when it comes to the treatment of the elderly patients who are diagnosed with chronic musculoskeletal pain disorder. Sample Data For the initial interview, the number of registered nurses will depends on the number of officially employed nurses within the two selected nursing homes. For the second part of the study, the researcher will follow Stewart and Shamdasani (1990) recommended range of participants for the survey questionnaires which is between 6 to 12 respondents from each of the selected health care setting. (Stewart & Shamdasani, 1990) Data Collection Method / Instrument(s) The data collection for the study will be divided into two processes: (a) initial interview with the nurses; and (b) selecting qualified elderly patients to answer the survey questionnaires. First, the researcher will conduct a one-on-one open ended interview with each of the nurses in order to determine who among the confined elderly patients have chronic musculoskeletal pain disorder aside from the type of treatment methods they administer to each of them. In order to ensure the content validity of the initial interview, the researcher will purposely use a list of structured question for the initial interview in case there is a need to refine the interview questionnaire along the way. (Roberts et al., 2002) All the information gathered during the initial interview will be recorded in order to ensure that the researcher has all the details needed for the research study. This information will provide the researcher a step-by-step management procedure related to both pharmacologic and non-pharmacologic musculoskeletal pain treatment approaches (Bernabei et al., 1998; American Pain Society Committee, 1995) that are being utilised within the two chosen nursing homes. When conducting an interview for a research study, the researcher should keep in mind that a strategic questioning is highly correlated to the accuracy and validity of the survey results such that the data that has been collected through an interview process and other data gathering techniques must always be appropriate to the research question of the study. For this reason, it is necessary for the interviewer to properly prepare the type of questions to be asked with the nurses. (Richards, 2006; 2003) Basically, there is absolutely no limitation as to how an interview should be conducted. According to Kvale (1996), the process of the interview heavily relies on the personal judgement of the researcher rather than a ‘context- and/or content-free rules of method.’ The statement of Kvale (1996) is also confirmed by the statement of Keith Richards (2006) such that ‘the personal dimension of the researcher is the secret of a successful qualitative research.’ The personal experience of the researcher includes the knowledge we obtained by going through the process of a research study or by simple reading and assessment of the materials we have read. After the initial interview with the nurses, the researcher will design a survey questionnaire for the elderly patients based on the gathered data during the initial interview with the organization staff. One way to develop a good quality survey questionnaire is to properly understand and analyse the main purpose of the research study. According to Keith Richard (2006), ‘understanding the research process is very important when a researcher decided to apply a qualitative research study in order to avoid heading into a wrong direction.’ Once the researcher has already written down a list of relevant question, it is essential for the researcher to go through it over and over again in order to figure out which of the questions need to be refined. Simple words will be used in the survey questionnaires to ensure that the qualified elderly patients will understand each questions being asked for the research study. The questions will focus more on the patients’ perception whether or not the pain assessment and management provided to them is effective or not. As soon as the questionnaire is ready, the researcher will personally approach the qualified patients to fill-up the questionnaires. Participants who are not able to read and write will be guided by the researcher through a personal interview. In a numeric scale of 1 – 10, the qualified participants will be asked to rate the instances wherein they have experienced the worst musculoskeletal pain. Using the same numeric scale, patients will be requested to rate the pain after receiving a treatment intervention including how it affects their overall activities of daily living (ADL). Data Analysis Statistical analysis will be conducted using the SPSS version 10 used in the study of Roberts, Adebajo and Long (2002). A descriptive statistics will be used to describe the sample gathered. A correlational statistics will be used in measuring and analyzing the gathered information. Research Schedule The study will last for at least two weeks from February 1 to 15. During the first two days, the researcher will focus on selecting two nursing homes close to his/her residence area followed by seeking permission to conduct a personal interview with the nurses in the selected nursing home A. As soon as the researcher has gathered the data, the researcher will design a survey questionnaire based on the interview result that was conducted in nursing home A. Starting from day 5, the researcher will start to seek permission to conduct a personal interview with the selected nursing home B. Similar to the process done with the selected nursing A, the researcher will also used the interview result in order to modify the survey questionnaire used in nursing home A. On day 8 onwards, the researcher will start to tally the survey questionnaires. As soon as the survey questionnaires have been tallied, the researcher will eventually analyze the survey result. (See Appendix III –Time Table for the Completion of the Study on page 21) Cost / Feasibility Analysis The estimated cost analysis for the research study is roughly £ 2,200. The bulk of the cost for the research study is the printing expenses amounting to half of the total estimated expenses. The researcher will spend at least two days in each of the selected nursing homes. Since the researcher will select two nursing homes within her own community, the food and travel allowance for the each whole day would be £ 200 per day. (See Table I – Estimated Cost of Research Study on page below) Assumptions and Limitations For the purposes of this research study, the following assumptions will be made: (1) the elderly patients will rate the degree of chronic musculoskeletal pain accurately; (2) the elderly patients will describe the impact of each of the musculoskeletal pain treatments accurately; (3) the chronic musculoskeletal pain experienced by the patients are being managed based on the best ability of the health care providers; and (4) the physiotherapy and nursing interventions are performed within the generally accepted standard. The limitation of the study includes: (1) the probability wherein the elderly patients may not be able to provide the data accurately; and (2) considering the small sample size of the data, the study is limited in terms of addressing the main research question of this study. Specifically the correlation between the impact of elderly patients who are diagnosed with a musculoskeletal pain disorder and the high mortality rate caused by a serious chronic pain is subject to further study. *** End *** Appendix I –Time Table for the Completion of the Study Events 1 Select Two Nursing Homes   2 Conduct a Personal Interview with the Nurses in Nursing Home A     3 Design a Survey Questionnaire Based on Interview Result     4 Conduct Actual Survey in Nursing Home A       5 Conduct Personal Interview in Nursing Home B     6 Design a Survey Questionnaire for Nursing Home B       7 Conduct Actual Survey in Nursing Home B     8 Tally Survey Questionnaires     9 Analyse Survey Results       10 Finalize Survey Results                                 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Day References: Ageing Population Panel. The Age Shift: Priorities for Action. (1999). London: Department of Trade and Industry. Amand, P. R., & Merek, C. C. (2008). What is Fibromyalgia?: What Your Doctor May Not Tell You About Fibromyalgia: The Program that Helps Boost Your Child's Energy Level. [Online] Retrieved January 22, 2008, from eNotAlone: http://www.enotalone.com/article/3394.html American Evaluation Association. (1994). In Guiding Principles for Evaluators - New Directions for Evaluation. pp. 66: 19 - 26. Asher, A. (2008). about.com: Back & Neck Pain. [Online] Retrieved January 21, 2008, from Musculoskeletal Sytem: http://backandneck.about.com/od/m/g/musculoskeletal.htm Badley, E., & Lee, J. (1987). The Consultant's Role in Contunuing Medical Education of General Practitioners: the Case of Rheumatology. British Medical Journal of Clinical Research Edition , 294:100 - 103. Bernabei et al. (1998). ‘Management of Pain in Elderly Patients with Cancer’ Sage Study Group. Systematic Assessment of Geriatric Drug use via Epidemiology. Journal of the American Medical Association , 279:1877 - 1882. Bosley, B. et al. (2004). Is Chronic Non-malignant Pain Associated with Decreased Appetite in Older Adults: Preliminary Evidence. Journal of the American Geriatic Society , 52(2):247 - 251. Brage, S., Sandanger, I., & Nygard, J. (2007). Emotional Distress as a Predictor for Low Back Disability: a Prospective 12-year Population-based Study. Spine , 32(2):269 - 274. Braverman, D. (2003). Interventions in Chronic Pain Management.New Frontiers in Pain Management: Complementary Techniques. Archives of Physical Medicine & Rehabilitation , 84(3):S45 - 49. Buckley, L., Leib, E., Curtularo, K., Vacek, P., & Cooper, S. (1996a). The Effects of Low Dose Corticosteroids on the Bone Mineral Density of Patients with Rheumatoid Arthritis. Journal of Rheumatology , 22:1055 - 1059. Buckley, L. M., Leib, E. S., Cartularo, K. S., Vacek, P. M., & Cooper, S. M. (1996b). Calcium and Vitamin D3 Supplementation Prevents Bone Loss in the Spine Secondary to Low-Dose Corticosteroids in Patients with Rheumatoid Arthritis: a Radomized, Double-Blind, Placebo-Controlled Trial. Annals of Internal Medicine , 125(12):961 - 968. Burns, J., Bruehl, S., & Quartana, P. (2006). Anger Managemetn Style and Hostility among Patients with Chronic Pain: Effects on Symptom-Specific Physiological Reactivity during Anger- and Sadness-recall Interviews. Psychosomatic Medicine , 68(5):786 - 793. Committee, A. P. (1995). Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer. Journal of the American Medical Association , 274(23):1874 - 1880. Daker-White, G., Carr, A., Harvey, I. et al. (1999). A Randomised Controlled Trial. Shifting Boundaries of Doctors and Physiotherapists in Orthopaedic Outpatient Departments. Jouranl of Epidemology Community Health , 53:643 - 650. Davis, P., & Suarez-Almazor, M. (1995). An Asssessment of the Needs of Family Physicians for a Rheumatology Continuing Medical Education Program: Resuls of a Pilot Project. Journal of Rheumatology , 22:1762 - 1765. Delaney, J., Leong, K., Watkins, A., & Brodie, D. (2002). The Short-Term Effects of Myofascial Trigger Point Massage Therapy on Cardiac Autonomic Tone in Healthy Subject. Journal of Advanced Nursing , 37(4):364 - 371. Dewar, A. (2006). Assessment and Management of Chronic Pain in the Older Person Living in the Community. Australian Journal of Advanced Nursing , 24(1):33 - 38. Dieppe, P., Chard, J., Faulkner, A., & Lohmander, S. (2000). 'Osteoarthritis' in Barton S. (ed) 'Clinical Evidence: A Compendium of the Best Available Evidence for Effective Healthcare'. BMJ Publishing Group , 4:649 - 673. Doherty, M., Abawi, J., & Patrick, M. (1990). Audit of Medical Inpatient Examinations: a Cry from the Joint. J R Coll Physicians , 24:115 - 118. Driscoll, D. L. (2006). Ethical Considerations in Primary Research. [Online] Retrieved January 23, 2008, from The Owl at Purdue: http://owl.english.purdue.edu/owl/resource/559/02/ Ehrmann Feldman, D., Shrier, I., Rossignol, M., & Abenhaim, L. (2002). Risk Factors for the Development of Neck and Upper Limb Pain in Adolescents. Spine , 27:523 - 528. El-Metwally, A., Salminen, J. J., Auvinen, A., Macfarlane, G., & Mikkelsson, M. (2007). Risk Factors for Development of Non-specific Musculoskeletal Pain in Preteens and Early Adolescents: a Prospective 1-year Follow-up Study. BMC Musculoskeletal Disorder , 8:46. Ferrell et al. (1990). Pain in the Nursing Home. Journal of the American Geriatric Society , 38(4): 409 - 414. Flato, B., Aasland, A., Vandvik, I., & Forre, O. (1997). Outcome and Predictive Factors in Children with Chronic Idiopathic Musculoskeletal Pain. Clinical and Experimental Rheumatology , 15:569 - 577. Fredriksson, K., Alfredsson, L., Koster, M. et al. (1999). Risk Factors for Neck and Upper Limb Disorders: Results from 24 Years of Follow Up. Occupational and Environmental Medicine , 56(1):59 - 66. Hagen, K., Kvien, T., & Bjorndal, A. (1997). Musculoskeletal Pain and Quality of Life in Patients with Non-inflammatory Joint Pain Compared to Rheumatoid Arthritis: a Population Survey. Journal of Rheumatology , 24:1703 - 1709. Hagg, O. et al. (2003). The Clinical Importance of Changes in Outcome Scores After Treatment for Chronic Low Back Pain. European Spine Journal , 12(1):12 - 20. Hall, G., Spector, T., Griffin, A., Jawad, A., Hall, M., & Doyle, D. (1993). The Effects of Rheumatoid Arthritis and Steroid Therapy on Bone Density in Post-Menopausal Women. Arthritis Rheumatology , 36:1510 - 1516. Hill, J. (1997). Patient Satisfaction in a Nurse-led Rheumatology Clinic. Journal of Advance Nursing , 25:347 - 354. Hong, W., Lee, Y., Chen, H., Pei, Y., & Wu, C. (2005). Influence of Heel Height and Shoe Insert on Comfort Perception and Biomechanical Performance of Young Female Adults during Walking. Foot & Ankle International , 26(12):1042 - 1048. Hosie, G. (2000). Teaching Rheumatology in Primary Care. Annals of Rheumatic Diseases , 59:500 - 503. Irvine, S., Munro, R., & Porter, D. (1995). Early Referral, Diagnosis, and Treatment of Rheumatoid Arthritis: Evidence for Changing Medical Practice. Annals of Rheumatic Diseases , 58:10 - 13. Jamison, R. N. (1996). Psychological Factors in Chronic Pain: Assessment and Treatment Issues. Journal of Back and Muskuloskeletal Rehabilitation , 7(2):79 - 95. Jones, A., Maddison, P., & Doherty, M. (1992). Teaching Rheumatology to Medical Students: Current Practice and Future Aims. J R Coll Physicians , 26: 41 - 43. Katz, D., Greene, L., Ali, A., & Faridi, Z. (2007). The Pain of Fibromyalgia Syndrome is due to Muscle Hypoperfusion Induced by Regional Vasomotor Dysregulation. Medical Hypotheses , 69(3):517 - 525. Kvale, S. (1996). 'Interviews: An Introduction to Qualitative Research Interviewing' in Richards K. (eds) 'Quality in Qualitative Research' Keith Richards IATEFL Research Sig Newsletter. August 2006. Issue 18. pp. 1 - 4. Laan, R., van Riel, P., van de Putte, L., van Erning, L., van't Hof, M., & Lemmens, J. (1993). Low-dose Prednisone Induces Rapid Reversible Axial Bone Loss in Patients with Rheumatoid Arthritis: a Randomized Controlled Study. Annals of Internal Medicine , 119:963 - 968. Lanyon, P., Pope, D., & Croft, P. (1995). Rheumatology Education and Management Skills in General Practice: a National Study of Trainees. Annals of Rheumatic Diseases , 54:735 - 739. Lundberg, U. (1999). Stress Responses in Low-Status Jobs and their Relationship to Health Risks: Musculoskeletal Disorders. Annals of the New York Academy of Sciences , 896:162 - 172. Martin, J., Meltzer, H., & Eliot, D. (1998). The Prevalence of Disability among Adults. London: Office of Population Censuses and Surveys. Menz, H., & Morris, M. (2005). Footwear Characteristics and Foot Problems in Older People. Gerontology , 51(5):346 - 351. Rickers, H., Deding, A.A., Christiansen, C., & Rodbro, P. (1984) Mineral Loss in Cortical and Trabecular Bone during High-dose Prednisone Treatment. (1984). Calcified Tissue International , 36:269 - 273. Nahit, E., Hunt, I., Dunn, G., Silman, A., & Macfarlane, G. (2003). Effects of Psychosocial and Individual Psychological Factors on the Onset of Musculoskeletal Pain: Common and Site-Specific Effects. Annals of the Rheumatic Diseases , 62:755 - 760. Pham, T., & Lafforgue, P. (2003). Reflex Sympathetic Dystrophy Syndrome and Neuromediators. Joint, Bone, Spine: Revue de Rhumatisme , 70(1):12 - 17. Qvindesland, A., & Jonsson, A. (1999). Articular Hypermobility in Icelandic 12-year-olds. Rheumatology , 38:1014–1016. Reid, G., Lang, B., & McGrath, P. (1997). Primary Juvenile Fibromyalgia: Psychological Adjustment, Family Functioning, Coping, and Functional Disability. Arthritis and Rheumatism , 40:752 - 760. Ribbers, G., Geurts, A., Stam, H., & Mulder, T. (2003). Pharmacologic Treatment of Complex Regional Pain Syndrome: a Conceptual Framework. Archives of Physiological Medicine Rehabilitation , 84:141 - 146. Richards, K. (2003). Qualitative Inquiry in TESOL. Hampshire, UK: Palgrave Macmillan, Ltd. Richards, K. (2006). Quality in Qualitative Research. Keith Richards IATEFL Research Sig Newsletter , Issue 18, pp. 1 - 4. Roberts, C., Adebajo, A., & Long, S. (2002). Improving the Quality of Care of Musculoskeletal Conditions in Primary Care. Rheumatology , 41:503 - 508. Ross, M., & Crook, J. (1998). Elderly Recipients of Home Nursing Services: Pain Disability and Functional Competence. Journal of Advanced Nursing , 27(6):1117 - 1126. Shrier, I., Ehrmann-Feldman, D., Rossignol, M., & Abenhaim, L. (2001). Risk Factors for Development of Lower Limb Pain in Adolescents. The Journal of Rheumatology , 28:604 - 609. Smith, E., Berry, H., & Scott, D. (1996). The Clinical Need for an Acute Rheumatology Referral Services. British Journal of Rheumatology , 35:389 - 391. Standard of Care for People with Regional Musculoskeletal Pain. (2007). London: Arthritis and Musculoskeletal Alliance (ARMA). Stewart, D., & Shamdasani, P. (1990). ‘Focus Groups: Theory and Practice’ in Clark L., Jones K., and Pennington K. (ed.) ‘Pain Assessment Practice with Nursing Home Residents’ Western Journal of Nursing Research. Newbury Park, CA: Sage. Underwood, M. (2004). Community Management of Knee Pain in Older People: Is Knww Pain the New Back Pain? Rheumatology , 43:2 - 3. Urwin, M., Symmons, D., Allison, T. et al. (1998). Estimating the Burder of Musculoskeletal Disorders inthe Community: the Comparative Prevalence of Symptoms at Different Anatomical Sites, and the Relation to Social Deprivation. Annals of Rheumatic Diseases , 57:649 - 655. van den Hout, J. et al. (2003). Secondary Prevention of Work-related Disability in Nonspecific Low Back Pain: Does Problem-solving Therapy Help? A Randomized Clinical Trial. Clinical Journal of Pain , 19(2):87 - 96. van der Windt, D., Koes, B., Deville, W., Boerke, A., de Jong, B., & Bouter, L. (1998). Effectiveness of Corticosteroid Injection versus Physiotherapy for Treatment of Painful Stiff Shoulder in Primary Care: a Randomised Trial. BMJ , 317:1292 - 1296. van Houdenhove, B., Neerinckx, E., Onghena, P., Lysens, R., & Vertommen, H. (2001). Premorbid 'Overactive' Lifestyle in Chronic Fatigue Syndrome and Fibromyalgia. An Etiological Factor or Proof of Good Citizenship? Journal of Psychosomatic Research , 51(4):571 - 576. van Tulder, M., Koes, B., Metsemakers, J., & Bouter, L. (1998). Chronic Low Back Pain in Primary Care: a Prospective Study on the Management and Course. Family Practice , 15:126 - 132. Waddell, G., & Burton, A. (2004). Concepts of Rehabilitation for the Management of Common Health Problems. 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