Background: This practical implementation report describes a primary care-based group parenting intervention—Child–Adult Relationship Enhancement in Primary Care (PriCARE)—and the approach taken to understand and strengthen the referral process for PriCARE within a pediatric primary care clinic through the deployment of synergistic implementation strategies to promote physician referrals. PriCARE has evidence of effectiveness for reducing child behavior problems, harsh and permissive parenting, and parent stress from three randomized controlled trials (RCTs). The integration of evidence-based parenting interventions into pediatric primary care is a promising means for widespread dissemination. Yet, even when integrated into this setting, the true reach will depend on parents knowing about and attending the intervention. A key factor in this process is the endorsement of and referral to the intervention by the child's pediatrician. Therefore, identifying strategies to improve physician referrals to parenting interventions embedded in primary care is worthy of investigation. Method: Through lessons learned from the RCTs and key informant interviews with stakeholders, we identified barriers and facilitators to physician referrals of eligible parent–child dyads to PriCARE. Based on this data, we selected and implemented five strategies to increase the PriCARE referral rate. We outline the selection process, the postulated synergistic interactions, and the results of these efforts. Conclusions: The following five discrete strategies were implemented: physician reminders, direct advertising to patients, incentives/public recognition, interpersonal patient narratives, and audit and feedback. These discrete strategies were synergistically combined to create a multifaceted approach to improve physician referrals. Following implementation, referrals increased from 13% to 55%. Continued development, application, and evaluation of implementation strategies to promote the uptake of evidence-based parenting interventions into general use in the primary care setting are discussed. Plain Language Summary There is strong evidence that parenting interventions are effective at improving child behavioral health outcomes when delivered in coordination with pediatric primary care. However, there is a lack of focus on the implementation, including the screening and referral process, of parenting interventions in the primary care setting. This is contributing to the delay in the scale-up of parenting interventions and to achieving public health impact. To address this gap, we identified barriers and facilitators to physician screening and referrals to a primary care-based parenting intervention, and selected and piloted five synergistic strategies to improve this critical process. This effort successfully increased physician referrals of eligible patients to the intervention from 13% to 55%. This demonstration project may help advance the implementation of evidence-based interventions by providing an example of how to develop and execute multilevel strategies to improve intervention referrals in a local context.
Introduction Migraine sufferers frequently complain of cervical pain during and in-between migraine attacks and studies suggest that chronic neck pain is a risk factor for high-frequency migraine, including chronic migraine. Increased headache frequency and chronic neck pain are, in turn, independently associated with cephalic cutaneous allodynia, a known risk factor for increased headache frequency. Objective To verify the influence that pain in migraine patients has on muscle performace during the cervical endurance test and whether the change in performance is due to pain during the test, neck muscle dysfunction or both. Methods Were evaluate 100 women stratified by diagnosis (migraine, cervical pain, both and none) and self-reported pain during the cervical muscle endurance test in flexion and extension (with or without headache and / or cervical pain during the endurance test). Pain during the test by numerical rate scale (NPRS, 0-10) and pain pressure threshold were collected for all groups. Migraine patients answered 12-item Allodynia Symptom. We used one-way analysis of variance with the Tukey’s HSD post hoc test analysis to contrast pressure pain threshold and endurance across groups. Differences in flexion and extension times were compared using the Welch T-test and the McNemar Test was used to compare differences in headache and neck pain incidence per study group during flexion and extension endurance tests. Results There are significantly differences in mean endurance during flexion between migraine and neck pain [34.4s (25)] relative to neck pain alone [45.2 (18)], migraine [40.2s (29)] and controls [57.5.4s (40)] (p = 0.04). On average, those who experienced headache during the flexion test sustained for significantly less time than those without headache during the test (27.80 versus 46.18 seconds, p<0.01); (To see the complete abstract, please, check out the PDF).
In predisposed individuals, migraine evolves into a stage of daily or nearly daily headaches, known as chronic migraine. Although relatively prevalent and debilitating at all ages, chronic migraine is particularly aggressive in the pediatric population. Several risk factors for chronic migraine have been identified, largely due to two very large longitudinal studies, the American Migraine Prevalence and Prevention Study (AMPP) and the Attention Brazil Project (ABP). This review summarizes lessons learned from these studies that included children from 5 to 19 years of age. We start by contextualizing chronic migraine and by offering a systematic approach to diagnosis. We then discuss pre-natal and post-natal risk factors for migraine transformation, and close by reviewing treatment strategies, ultimately attempting to offer a meaningful overview of chronic migraine in pre-adults based on our experience conducting these studies.
Introdução O relato da dor cervical nos pacientes com migrânea pode contribuir negativamente para o aumento das crises de cefaleia e severidade da alodínia cutânea, com impacto nas atividades de vida diária. Objetivo Verificar se o desempenho de mulheres com migrânea durante o teste de resistência muscular cervical é afetado pelo diagnóstico clínico de migrânea e/ou dor cervical, pelo relato de dor de cabeça e/ou pescoço ou ambos os componentes. Métodos 100 mulheres estratificadas por diagnóstico (migrânea, dor cervical, ambas e nenhuma) e pela dor autorreferida (com ou sem cefaleia e/ou dor cervical) realizaram o teste de resistência muscular cervical. As participantes foram questionadas se tiveram dor no pescoço e /ou cabeça. Foi realizado teste T de Welch e o teste McNemar. Resultados Para o diagnóstico, os dados revelaram que durante o teste de resistência em flexão, os pacientes com migrânea e dor cervical apresentaram menor resistência quando comparados ao controle (p<0,05). Durante a extensão, os grupos de dor cervical com ou sem migrânea tiveram tempo de sustentação menor que o grupo controle (p <0,05). Na estratificação quanto ao relato de dor durante o teste em flexão e extensão, os dados mostraram que aqueles que relataram cefaleia, sustentaram por menos tempo do que aqueles sem cefaleia. Resultados semelhantes foram observados ao comparar aqueles com dor de cabeça e pescoço e sem dor durante o teste (p <0,05). Conclusão O diagnóstico clínico não foi único fator decisivo para o desempenho da resistência muscular cervical. A presença do relato de cefaleia associada ou não à dor no pescoço após o teste também limitou a atividade. Portanto, há um componente de sensibilização central que proporciona a alteração no desempenho, porém ainda não é possível determinar se é o fator que atua diretamente no baixo desempenho de migranosas.
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