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Bikini season is right around the corner, but before you start ditching solid food for the newest "cleanse" on the market why not try a simple wellness trick that helps cleanse your body from the inside out—no starvation necessary. With a quick five minutes in the morning you can help your body cleanse itself without sacrificing your paycheck!
Dry Brushing is an ancient practice that boasts a number of health benefits including, dead skin exfoliation, lymphatic system stimulation, unclogging pores, decongesting skin and best bikini benefit of all, dry brushing helps reduce cellulite. Yes, you read that correctly.
Dry brushing gives your lymphatic system a morning reboot which helps push and eliminate toxins from your body. Cellulite, AKA toxic material your body has accumulated that are trapped in your fat cells (ugh!), will be gently broken down by dry brushing helping your body eliminate them. This can all be done in as little as five minutes a day, right before you take a shower.
So, how does it work. First you need a brush. We love Yerba Prima brush that you can buy here or at your local Whole Foods or health food store for a little over 10 bucks. Dry brushing is simple, but don't be thrown off if you find it a tad bit uncomfortable at first. It can feel strange to rub a brush on your dry skin at first, but trust us—once you get into the habit, it will become more enjoyable and energizing.
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Make dry brushing a daily habit for the best skin benefits, and your skin will be bikini ready in no time. Have you tried dry brushing? Let us know if the comments below!

subset: commoncrawl


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Where are police auctions conducted?
Where are police auctions of property conducted? Does the Los Angeles Police Department have a lost and found section? How can I obtain an item with an LAPD logo on it such as a badge…
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Martha Firestone Ford, who took over ownership of the Detroit Lions when her husband, William, died in 2014, has won praise for being upfront with fans and sticking it to NFL Commissioner Roger Goodell. But it sounds like you better not cross her, at least that's what radio station 97.1 The Ticket is saying. The station was the flagship for the team for 18 years, but the team recently decided to take their business elsewhere, According to The Ticket, this was due, in part, to their refusal to let the team censor content, paticularly commentator Mike Valenti, Deadspin reports. Elizabeth Parkinson, senior vice president of marketing and corporate sponsorships for the Lions, fired back: "If we were trying to practice any sort of censorship, we certainly would've done it (the switch) much sooner." Awkward. (Brandon Weigel)
Here's the hottest menu item this Thanksgiving: Patti LaBelle's sweet potato pie, available at Walmart. No, really. The pies debuted in September at a modest $3.48 per pie to mild fanfare, but now the mega-retailer can't keep them on the shelves, NPR reports. They're going on eBay for $40 and slices are being offered on Cragislist for $10 a pop. Why the change? This viral video by singer James Wright. "In it, he unboxes and eats the Patti LaBelle pie while breaking into song like he's in a Patti LaBelle musical (with the occasional profanity thrown in)," NPR reports. A Walmart VP says stores were selling a pie a second last weekend. That's a lot of pies. (Brandon Weigel)
In the wake of the recent terrorist attacks in Paris, French culture minister Fleur Pellerin has presented a $6 million solidarity fund to support the recovery of the theaters, museums, and cinemas affected by the attacks, which killed 129 people including including German art critic Fabian Stech and French artist Alban Denuitt. President Francois Hollande also announced that laws may be created to allow French museums to temporarily safeguard at-risk artifacts from Iraq and Syria—part of a 50-point plan created by Louvre director Jean-Luc Martinez that was commissioned after members of ISIS blew up several ancient buildings in Palmyra, including the 2,000-year-old Temple of Bel, back in June. "The right to asylum applies to people," Hollande said in his announcement, "but asylum also applies to works, [to] world heritage." (Maura Callahan)


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The work of the NET teams is the primary activity of NET Ministries. Each year approximately 175 young adults ages 18-28 volunteer nine months of their lives to serve on the NET teams. These young adults are placed on 16 different teams of 8-12 people. For nine months, these teams become like family for each other as they work side by side sharing what God has done in their lives. For countless youth across the country this message of God's love and power is brought to them in a personal way.
Teammate relationships will be among the deepest, most challenging and most rewarding relationships a young adult will ever have. They will laugh, cry, and struggle alongside one another. Through it all they'll grow together. They will learn what it means to truly love and to truly be loved. Most often, it is not the ministry skills that the young people notice on a NET retreat, but the love that the team members have for one another.
Two types of ministry teams are currently being trained and sent out, Retreat Teams and Discipleship Teams.
NET Ministries currently has 11 retreat teams composed of 10 to 12 members who facilitate retreats six days a week for youth in junior high and high school. Each team travels to specific dioceses and spends time serving the individual parishes there.
In an average 9 month NET season, each retreat team will:
• Travel 20,000 miles
• Serve 7 to 8 dioceses
• Facilitate nearly 150 retreats
• Stay in 125 host homes
• Reach 8,500 young people one-on-one with the Gospel
With such a busy ministry schedule, a retreat team member's van is their home sweet home and one of the best places to hang out and recharge with their teammates.
The ministry of each team is focused on retreats which can span 4 hours to 3 days. Large group talks, skits and dramas, small group discussions, and time for individual prayer are all components of each retreat. Throughout the entire retreat, the youth are extended the invitation to embrace their faith and cultivate a personal relationship with Christ. Learn how to bring a NET team to your parish. Click here to request more info or book a retreat!
Four of NET's 16 ministry teams are Discipleship Teams. These teams serve in one specific parish or school for their entire NET year. While in the area they help facilitate the youth ministry or campus ministry program including things such as:
• High School Youth Group
• Junior High Ministry
• Discipleship Groups
• Young Adult/Core Team Ministry
• Teen Mass
• Retreats for Parish Youth
In addition, teams will reach out to teens who are not actively involved in parish life by going to local teen events/sporting events, eating lunch with youth at school and or popular hangout spots, and simply being a light to the community.
While in a parish or school, the teams stay with host families in the community for extended amounts of time which provides the chance to enter into family life and minister to the families as well. Discipleship Team ministry is focused on long term evangelization and building relationships that will grow throughout the year and beyond.
Missionary Blogs
Not Easy, But Worth It: Lent on NET | Team 1
What's good, blog-reading-type-folk? It's us again, Home Team. Today we want to talk about Lent; the good times, the bad times, and the other times. We hope that your Lent has been fruitful, and as we come to a close of this season we want to reflect on the everyday...
Return to the Lord | Team 10
"And the Lord said to him, 'Go through the city, through Jerusalem and put a mark on the foreheads of the men who sigh and groan over all the abominations that are committed in it,'" (Ezekiel 9:4). Holy Lent from Team 10! Well, we're still at it: getting our butts...
That's the Way the Cookie Crumbles | Team 12
"The LORD's acts of mercy are not exhausted, his compassion is not spent; They are renewed each morning—great is your faithfulness!" (Lam. 3:22-23). One team day not too long ago, our merry band of NETters came into the office after a lovely walk in downtown Dallas. A...


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Development of an education and self-management intervention for chronic headache – CHESS trial (Chronic Headache Education and Self-management Study)
Self-management interventions are well recognised and widely used in chronic conditions. Their application to chronic headaches has been limited and generally of low quality. We describe here our process for developing an evidence based, and theory driven, education and self-management intervention for those living with chronic headache.
Our intervention was designed using several core information sources; the results of three systematic reviews, qualitative material from those living with chronic headaches, our knowledge from existing self-management interventions; and finally collaborative input from a multidisciplinary team of clinicians, academics, patients, and charity partners. We manualised the intervention and associated training as a package for use in a feasibility study. We made adaptations for its use in a randomised controlled trial.
We piloted the intervention in four groups with a total of 18 participants. Qualitative feedback from 12 participants and five facilitators allowed the intervention to be refined for the main randomised controlled trial. Some of the key changes included shortening of the overall intervention, changes to the originally planned facilitators and spreading the facilitator training over three days rather than two.
We are now testing the final revised intervention in a randomised controlled trial of its clinical and cost effectiveness. The group component of the intervention is delivered over two days with the first day focused on living, understanding and dealing with chronic headaches and the second day exploring how to adapt and take control of one's life with chronic headaches.
Our pilot work indicates that our intervention is feasible to deliver, and with the relevant changes would be acceptable for use with this population. Our randomised control trial is ongoing. We anticipate publishing final results in 2021.
Trial registration
ISRCTN79708100. Registered 16th December 2015, http://www.isrctn.com/ISRCTN79708100
KeywordsChronic headache Tension type headache Migraine Self-management Primary care Behaviour change Intervention development
Allied Health Professional
Cognitive Behavioural Therapy
Chronic Headache Education and Self-management Study
COping with persistent Pain, Effectiveness Research into Self-management
General Practitioner
Medical Research Council
National Health Service
National Institute for Health and Care Excellence
Patient and Public Involvement
Randomised Controlled Trial
Chronic headaches affect 2–3% of the population. Globally migraine, medication overuse headache and tension type headache are, respectively, the second, sixth and 12th leading causes of disability from neurological disorders [1]. Around 4% of UK primary care consultations and 30% of neurology outpatient appointments are due to headache disorders [2, 3, 4]. The annual direct treatment cost to the UK National Health Service (NHS) is £1 billion [5]. As headache disorders are most prevalent among the working age population they have a large economic impact. The annual cost of headache disorders in the UK is between £5–7 billion; primarily due to lost production [6, 7].
Managing chronic headaches can be challenging, the focus has tended to be on pharmacological interventions. Pharmacological management has tended to focus on episodic migraine, with few studies focusing on chronic headaches [8]. Only topiramate and OnabotulinumtoxinA have been shown to reduced headache days for those with chronic migraine [9, 10, 11, 12, 13]. The impact on quality of life has not been explored in trials and the overall use of other pharmacological strategies is very limited and of poor quality amongst a chronic headache population. The UK National Institute for Health and Care Excellence (NICE) published guidance on headaches in September 2012. Apart from a recommendation to consider a course of acupuncture for people with chronic migraine or chronic tension type headache, the guideline developers did not find suitable evidence to allow recommendations on non-pharmacological treatments for people with chronic headache [14].
There is good evidence for supportive self-management programmes for long-term conditions [15]. Such programmes have been used in a range of chronic conditions [16, 17, 18]. These use patient education and behaviour change strategies to encourage those living with chronic conditions to engage and take an active role in managing their own condition and to minimise the impact this condition has on individual's physical and psychological functioning. Chronic conditions can have a substantial impact on individual's lives [19, 20] therefore a focus on a biopsychosocial approach taking into account physical, psychological and social factors is appropriate [21]. There has been limited high quality evidence for the use of self-management interventions in the treatment of chronic headaches [22], hence the need for further research.
There is some suggestion of an association between chronic headaches and chronic musculoskeletal pain [23, 24]. A systematic review of the association between headache and low back pain found that the odds ratio for the association ranged from 1.55 to 8.0 in different studies [25]. This association maybe linked to central sensitisation, which may provide a common pathway for chronic headache and other chronic pain syndromes [26, 27]. It is therefore appropriate to draw on the current evidence base from other painful chronic conditions to inform strategies to facilitate effective self-management of chronic headaches.
Building on this evidence we have been funded to develop and test a group self-management support programme for people living with chronic headaches (funded by the NIHR Programme Grants for Applied Research programme - RP-PG-1212-20,018) [28]. We describe here the development and initial evaluation of an education and self-management support intervention for people living with chronic headache. The specific aim of the programme is to enable people with chronic headache to manage their pain better and to improve their quality of life. For our main randomised controlled trial, we are testing the hypothesis that amongst adults with chronic headache, the provision of a self-management support programme in addition to best usual NHS care will help to improve headache related quality of life.
An overview of our intervention development process using an adapted version of the Person-Based Approach
Intervention development stage
Processes undertaken
Exploration of evidence base to identify patient needs and challenges
Synthesis of evidence using systemic reviews:
a. education and self-management interventions for chronic headache [22]
b. lived experiences review [35]
c. prognostic factors for chronic headache [36]
Qualitative material collected via interviews with people living with chronic headache
Outline of needs and challenges to be addressed to meet overall intervention objectives
Creating an outline of the intervention aims and objectives including the key features and components to achieve the objectives using:
1. Our experience of developing and testing an intervention package for people living with chronic musculoskeletal pain, COping with persistent Pain, Effectiveness Research into Self-management (COPERS study) [50, 51]
2. Input from a multidisciplinary team of clinicians, academics, PPI, and charity partners at a collaborative intervention design meeting
3. Outcomes from a classification development day which aimed to inform the development of a logic model to support the classification of chronic headache disorders. Input into this day came from neurologists, headache specialist general practitioners, headache specialist nurses, and people with chronic headache
Development, evaluation and implementation – acceptability and feasibility
Final intervention package evaluated including manuals and training
Feedback from our PPI members attending the intervention design day. Qualitative interviews with facilitators (nurses and lay) and participants from the feasibility study to help refine the intervention for the main RCT.
Throughout the process of designing this intervention, we have drawn upon the views and opinions of our PPI partners to make sure what is produced would be acceptable and useful for those living with chronic headaches. Our PPI support comes from key members of the leading headache charities, members attending our intervention design day, our lay facilitators (who themselves live with chronic headaches) and a wider PPI reference group who have volunteered to support the overall CHESS study with PPI needs.
The development and initial evaluation of the intervention package was just one component of the CHESS feasibility study. A detailed account of the full feasibility phase are described elsewhere [34].
Planning phase - systematic reviews
Summary of results from reviews and influences on intervention design
Key findings
Influences on intervention design
Style and content review [22]
To review the effectiveness of self-management interventions for headaches and highlight the differential components included and delivery methods used
Inclusion of CBT
The overall intervention is informed by the core principles of cognitive behavioural therapy (CBT). The focus being on unhelpful thinking patterns and the need to recognise such thought processes and look for alternatives that are more helpful. Participants have the opportunity to explore the different types of unhelpful thought patterns and subsequently reflect on the challenges these create and ways to make them more helpful/manageable.
Inclusion of education
The programme is an educational and self-management intervention and therefore includes topics that carry a large educational component. This includes topics such as 'headache information and mechanisms' and 'medication management.'
Inclusion of mindfulness
As part of a taster session, mindfulness is included. Participants are provided with a mindfulness CD for home practice.
Inclusion of relaxation
Relaxation is included as a taster session and participants are provided with a copy of the relaxation CD for home practice.
Group interventions more effective
The intervention is group based, aiming to get between 8 and 10 participants per group.
Face to face and remote delivery did not make much of a difference
As this is a complex intervention with several components, we felt a face-to-face, group intervention with a built in one to one consultation would be the best option based on previous experience from the team in delivering complex interventions.
Homework - no difference in studies offering this and not
We included homework as part of our intervention to enable bedding in of information and discussions from day one and to allow any uncertainties to be clarified on day 2. Participants are encouraged to make use of the relaxation CD and to watch the headache DVD.
Email/telephone support – no difference in studies offering this and not
Telephone follow-up is provided as a means of supporting those who are implementing changes and in particular those who might be withdrawing from medication. The frequency of these calls are individually negotiated between the nurse and the participant.
No indication that delivery by a Psychologist or Psychotherapist was any more or less effective than a nurse or Allied Health Professional (AHP)
The collaborative team carefully considered who should facilitate the delivery of the intervention. Due to the medical aspects of headaches around mechanisms, medication and headache classification a nurse was deemed most appropriate.
Lived experiences review [35]
To synthesis the qualitative literature on the lived experience of people with chronic headache disorder
Headaches act as a driver to increase medication
We have specifically included a session on medication to allow exploration of acute and preventative medication. Focus is also given to the concept of medication overuse headaches and subsequently the opportunity to discuss this during a one to one consultation.
Headaches lead to avoidance in planning
The intervention includes the headache pain cycle and the need to break the cycle. We explore the skills associated with identifying barriers to change and using problem solving and goal setting as a means to engaging in meaningful activity. Participants are encouraged to complete their own goal-setting plan and to bring that to the one to one appointment for discussion.
Headaches encouraged changes in sleep patterns
Sleep management is included as a session to enable participants to understand the link between sleep and thoughts and subsequently look at what is, and is not, recommended for good sleep management.
Headaches a driver to stopping doing things
The headache pain cycle is used to discuss a feeling of being trapped and therefore withdrawing. This is further explored to identify strategies to help break this cycle.
A sense of loss of control
The whole intervention is designed to educate and encourage those with chronic headaches to explore strategies to help them better manage their headaches and improve their quality of life. As part of this journey we explore the concept of control and the implication this can have on headaches.
Prognostic review [36]
To identify predictors of prognosis in studies of those with chronic headache
Depression and anxiety
The intervention includes topics around the link between mood and headaches and the impact this can have. We provide participants with a handout outlining the possible symptoms of depression and advise to seek support from their GP if they are struggling with these. Mindfulness and relaxation are built in as strategies to help manage mood and anxiety.
Medication overuse
This is covered as a topic in the facilitated group sessions and then further discussed during the one to one consultation, if relevant.
Poor sleep
The concept of a balanced and healthy lifestyle is facilitated as a topic during the group sessions. As part of this, sleep and effective sleep management strategies are discussed.
High stress
Sessions on managing stress and anxiety are included. Participants are encouraged to explore the impact of stress and anxiety and subsequently look at strategies for management. Relaxation and mindfulness are introduced as strategies to manage stress and participants are encouraged to practice these at home.
Headache management self-efficacy
The course is designed in inform, empower and build confidence in those with headache to take control and use self-management strategies to help them manage their headaches better.
Planning phase - qualitative interview study
We conducted qualitative interviews to inform the intervention design. This interview data and the lived experience systematic review both aimed to ensure that the intervention design included a strong patient focus. Migraine Action,1 one of the charity partners in CHESS, sent letters on the trial's behalf to their members within a predefined geographical region for ease of travel (100 members resided in this area). Interviews were face to face in people's homes and were audio recorded after taking informed consent. Topic guides explored their experiences of what might be helpful, or unhelpful, treatment strategies and where they sought information regarding their headaches. Interviews were transcribed, anonymised and analysed thematically. All data were collected and held in accordance with data protection guidelines.
From the 100 invitation letters sent out, we received 21 responses. Of these responses, five had headaches for < 15 days per month, three had no headaches, three were under the age of 18 years and two were not interested in the study. Of the eight that met our inclusion criteria of headaches on > 15 days per month for at least three months, one had new daily persistent headache and was therefore excluded. We interviewed seven people; the results of these interviews were presented at the intervention development day.
When participants were asked about things that they had tried which were helpful for their headaches they spoke about a vast array of treatments and strategies. These included; belonging to organisations for information and support, seeing approachable and knowledgeable doctors, seeing different therapists (physiotherapists, acupuncturist, counsellor, craniosacral therapist), meditation/relaxation, distraction techniques, being outdoors, having social support from people who understand, having a positive mind-set, Yoga, Pilates and breathing techniques. However, what was helpful to some was often unhelpful to others and many of the things tried were out of the scope of our intervention.
When describing their medication use, interviewees spoke of 'mixing and matching', and 'trial and error', some medication working at one time and not at another. Side effects were an important feature and two interviewees voiced worries about their medication being rationed. Exact medication use was difficult to ascertain at interview. This was an area for us to explore further in the feasibility study interviews.
We asked participants for their views about what we should consider for inclusion in an education and self-management group intervention. Suggestions included getting peer support (group meetings); developing skills in stress management, relaxation/meditation; learning about triggers, lifestyle factors and medication; having information in one place; having education for others such as family and employers; gaining expert support and finding out about the latest research and advances.
They also gave us some practical points about running a group for people with frequent headache, this included running of the course in a neutral environment so that it was not too medical (such as a hospital setting). They felt small groups were important and there should be regular breaks throughout the day. An option to have groups in the evening was also suggested for those that work or cannot attend during the day.
Design phase - knowledge from existing intervention
With the associated links between chronic headaches and those with chronic pain, we have drawn upon the knowledge and experience of intervention design and delivery from those involved in the design and running of the COPERS study [37]. Key members of that study are part of the CHESS study team. This was a randomised control trial of a group education and self-management intervention for those living with chronic pain. This was a complex intervention designed using underpinning psychological theory and the guidance of the MRC framework for designing complex interventions [32, 33]. This team conducted two reviews to help inform their intervention design and the results of these reviews have been examined as part of the CHESS intervention development [38, 39]. The COPERS intervention was proven to be acceptable and effective in the medium-term for depression, anxiety, social integration and support, pain acceptance, and self-efficacy in pain management. There are also long-term positive effects for depression, and social integration and support.
The basic structure and content of the COPERS intervention was used to inform the CHESS intervention as was the use of groups so that people could learn from each other and the use of lay facilitators to jointly facilitate with the nurse. Having two facilitators allows for easier management of challenges or difficulties without the need to disrupt the rest of the group. Other experience used to inform the CHESS intervention was holding courses in familiar accessible locations and that clinicians from different disciplines were capable of delivering the intervention.
Design phase – Theoretical underpinnings
Theoretical underpinnings and behaviour change rational and techniques for CHESS intervention
Theoretical underpinnings
Behaviour change taxonomy
Introduction to the course and each other
To make participants feel comfortable and relaxed and encouraging them to participate by introducing themselves to the group.
Biopsychosocial model, social cognitive theory
Breaking barriers and encouraging self and social awareness. Providing opportunity for change through social support, education and managing expectations
Understanding chronic headaches and acceptance
To increase understanding of chronic headaches and reasons for it and to introduce the concept of acceptance and need for self-management.
Principles of acceptance theory, biopsychosocial model
Information and education to increase capability, awareness and shape knowledge. Emotional regulation to enable acceptance
Mind, body and pain link
To start to introduce the concept that pain and mood are linked and that mood can have an influence on headaches. To explain the pain cycle individuals can get stuck in due to the unhelpful things we do, and explore the strategies that can be used to help break the cycle.
Cognitive behaviour theory, fear avoidance model, biopsychosocial model
Education to help shape knowledge and promote capability. Understanding emotional consequence
Dealing with unhelpful thought patterns
To introduce ideas about unhelpful thoughts, automatic thoughts and error in thinking. To understand the impact of unhelpful thinking and how such thought patterns can keep people in the pain cycle and explore ways to reframe these thoughts.
Cognitive behavioural theory, health beliefs model, Biopsychosocial model
Promotes capability in identification and reframing of thoughts
To clarify learning from day one and provide a reminder for things to do before day 2.
Provide the opportunity for embedding learning through summary and promotion of watching the DVD, promoting self-monitoring (headache diary), encourage behavioural practice (relaxation)
To understand and empathise with the group and ascertain current thoughts.
Social cognitive theory, biopsychosocial model
Social support, feedback and monitoring of behaviour, social comparison through feedback, social reward and positive reinforcement
Back to basics
To get participants to think about future goals and explore these by identifying possible barriers, potential solutions and develop an associated action plan. To learn about the importance of lifestyle change by being aware of triggers.
Theory of planned behaviour and reasoned action, Cognitive behaviour theory, biopsychosocial model
Use of education and strategies to encourage enablement and knowledge acquisition. Use of problem solving, personalised goal setting, and action planning. Reflections on individuals capability, motivation and opportunity for change
Making headaches more manageable
To understand the link between stress, anxiety and headaches, and look for strategies that may help manage this better. To understand the link between sleep, anxiety and headaches to help identify strategies that may help improve sleep quality. To help practice the art of being in the present.
Cognitive behaviour theory, Theory of planned behaviour and reasoned action, biopsychosocial model
Regulation and reducing negative emotions. Education and shaping knowledge through instruction on how to perform relaxation and mindfulness with an embedded in session practice. Incentivisation to engage through provision of material to enable behavioural practice and habit formation
Treatment options
To increase knowledge about medication and use of medication for chronic headaches.
Social cognitive model, biopsychosocial model
Information about health consequence, pharmacological support (regulation), self-monitoring (use of headache diaries)
Communication – explaining your headaches to others
To improve listening and communication skills to aid better relationships. To reflect on consulting behaviour and promote effective communication and constructive consultations.
biopsychosocial model
To help with social integration. To promote effective healthcare utilisation.
Monitoring of outcomes from previous experiences, use of planning and problem solving, improving communication skills
Future management
To know what to do when experiencing a setback or a flare up.
Cognitive behaviour theory, Theory of planned behaviour and reasoned action, acceptance and commitment therapy. Biopsychosocial model
Preparation and embedded learning.
To clarify learning from the two days and introduce the structure of the one to one sessions
Embedding learning
One to one session with nurse
To make a classification of headache type and discuss medication management based on the classification. To also review lifestyle factors and goal setting to enable the participant to engage in behaviour change.
biopsychosocial model
Provision of pharmacological information and support as well as embedded learning. Review of goals including reflection on performance and consequence of change. Self-monitoring of headaches and subsequent health, social and environmental consequence. Social reward and positive reinforcement
Grounded in the evidence base from our review, we built in 'taster' sessions around relaxation and mindfulness. The sessions provide participant with the opportunity to participate via instruction on how to engage in relaxation and mindfulness. Participants then have the opportunity to take away material to allow for home practice with the aim to encourage regular practice and habit formation in the long- term.
We have also produced a DVD for participants to share with family and friends. The DVD is aimed to be informative, reiterating the core messages from the course as well as portraying what it is like to live with chronic headaches. This was developed in response to suggestions from PPI members at the intervention design day as well as the qualitative review and interviews that suggested those living with chronic headaches feel others do not understand.
Design phase - collaborative intervention design meeting
This meeting was attended by clinicians including a neurologist and two general practitioners, directors from two leading headache charities (Migraine Action; National Migraine Centre), three lay people living with chronic headaches, psychologists with expertise in self-management and behaviour change, academics and researchers (18 attendees in total). The multidisciplinary team bring together clinical expertise in the management of chronic conditions including headaches and pain as well as expertise in behaviour change and self-management. We drew on this experience to inform the development of the intervention.
The day comprised of short presentations on the results from the three systematic reviews, main findings from the qualitative interviews, an overall study summary from COPERS [37] and a summary of the main outcomes from a classification day which took place to inform the design of a logic model to allow chronic headaches to be classified. The classification day comprised of facilitated discussions on core questions to help inform the development of a logic model. The outcomes from these small group discussions were discussed in a large plenary session and this information was used to help develop and refine a logic model to be used in the study and intervention process. Full details have been published elsewhere [49].
During the intervention design meeting, presentations followed facilitated discussion about the results, what the tailored education self-management intervention should look like, what ongoing support participants would need and what the control intervention should be. We have had input from the three leading headache charities. We have also had the input from three lay members who attended the intervention design day and were involved in the discussions and decisions. After the meeting, a drafting document was circulated which provided all those that attended the opportunity to feedback. This combined input has helped shape the intervention.
Here we describe the intervention package we developed for implementation based on this work and how we implemented, evaluated and refined ready for use in our RCT.
The CHESS intervention is embedded in the biopsychosocial model, which acknowledges that long-term conditions have physical, psychological and social implication on individuals and therefore management should focus on a combination of these factors. The overall aim of the course was to encourage and enable those with chronic headache to manage and cope with their pain better, to improve their quality of life despite their headache.
Feasibility intervention design
We designed an education and self-management intervention delivered and facilitated by a non-headache specialist nurse and lay facilitator (someone who lives with chronic headaches). The intervention was delivered over two full days (10:00–15:00) followed by a one to one consultation with the nurse facilitator (agreed at a time convenient for the nurse and participant, approximately a week after the group sessions, lasting up to two hours). This was then followed by a half-day group follow-up session (10:00–12:30). The course was designed for between 8 and 10 participants.
We interviewed the five facilitators and 12 of the participants to capture their feedback and experience. We also collected written participant feedback at the end of the course and asked facilitators to provide written reflective logs after each day of facilitation.
Summary of the main changes to the intervention following facilitator and participant feedback
Collated feedback summary
Changes to the intervention
Facilitators for the main randomised controlled trial
During the feasibility phase it had been difficult for the lay facilitators to commit to running groups due to their own chronic headaches. This was collaboratively discussed and there was agreement to use an AHP who is registered with an appropriate regulatory body rather than a lay facilitator for the main RCT.
Length of the course
The original 2.5 days was challenging for participants due to work and family commitments. For this reason the half day follow-up was removed. We felt confident that any issues could be raised during the one to one session and subsequent telephone follow-up. The content due to be covered on the follow-up day was merged into day two of the course. This was possible as other topics had been removed and/or revised. The fourth group was run using this two day format.
Timing of the sessions
Originally we had planned to run the two days consecutively, with the follow-up day approximately two weeks later. Two groups were run using this format but participants struggled with some experiencing headaches. The third group was run using a weekly format with one day delivered each week with the follow-up day two weeks after the second group session. In between the second full day and follow-up session, participants had their one to one consultation with the nurse.
Merging of topics related to unhelpful thinking patterns and reframing negative thoughts to positive thoughts
Facilitators found these session difficult to facilitate as they felt disjointed. By merging the sessions it allowed more clarity on the importance of recognising unhelpful thought patterns and subsequently using questions to challenge them and look for more helpful alternatives.
Merging physical activity as a topic into lifestyle factors
Physical activity was included as a separate topic, however it fitted better under the theme of lifestyle factors therefore this topic was integrated into this section.
Removal of session on emerging and complementary treatments
The nurses felt this session was difficult to deliver because of the level of knowledge required and the questions presented to them. For this reason, as well as our understanding that most of these treatments would not be readily available on the NHS we decided to remove this session. We provided participants with a handout detailing the websites of some of the leading headache charities where they could find more information on treatments.
Addition of summary and reminders at the end of day 1
An overall summary table of the content covered was added to allow participants to reflect on the material covered and understand the links between the sessions. We also include some reminders to ensure participants continued to complete the headache diary, watched the DVD and practiced the relaxation where possible.
Changes to some of the session and module names
This was done to improve clarity.
Mindfulness session
This session was broadened to mindfulness and relaxation to give participants the opportunity to understand the differences between the two and have the opportunity to practice these at home.
CHESS intervention training
The training for facilitators in the feasibility phase was delivered over two full consecutive days. The training was delivered by two psychologists, a general practitioner, a neurologist and a nurse by background. From the feedback we found many of the facilitators struggled with the amount of information covered and that they would have liked sometime between the two training sessions. Taking into consideration the feedback, we revised the training for the RCT, it is now delivered over three days, with the first two days as consecutive days covering the group educational and self-management components. This is then followed by a third day, a week later, to cover the training for the one to one session and follow-up phone calls.
Further one to one support was provided to each nurse ahead of their first one to one sessions to recap on the logic model and medication advice.
In addition, all facilitators are supported individually as and when required by the intervention design team.
Some other more practical issues identified by participants included the need to carefully consider venues for delivering CHESS especially in relation to seating, temperature and lighting. Each venue selected for the CHESS delivery is assessed for suitability by the trial team. The facilitator manual provides a reminder for to facilitators to assess the temperature and lighting and to accommodate needs where possible.
Final modules and course content for the CHESS intervention
Content of sessions
1. Living, understanding and dealing with chronic headaches
1. Introduction to the course and each other
Session 1: Welcome and introductions
Session 2: Course overview
2. Understanding chronic headaches and acceptance
Session 3. Headache information and mechanisms
Session 4. Acceptance of chronic headaches
Taster activity – Relaxation and breathing
3. Mind, body and pain link
Session 5. Impact of thoughts, mood and emotions on headaches
Session 6. Headache cycle and breaking the cycle
4. Dealing with unhelpful thought patterns
Session 7. Unhelpful thinking patterns: recognising and finding alternatives
5. Summary
Session 8: Summary and reminders from day 1
2. Learning how to adapt and take control of your life with chronic headaches
1. Reflections
Session 9. Reflections from Day 1
2. Back to basics
Session 10. Identifying barriers to change and exploring problem solving and goal setting
Session 11. Lifestyle factors and impact on headaches
3. Making headaches more manageable
Session 12. Managing stress and anxiety
Session 13. Managing sleep better
Session 14. Mindfulness and relaxation for headaches
Taster activity – Mindfulness practice
5. Treatment options
Session 15. Medication management
6. Communication – explaining your headaches to others
Session 16. Relationships and communication with family, carers and friends
Session 17. Communicating better with Health Professionals
7. Future management
Session 18. Managing setbacks – what to do when things don't go to plan
8. Summary
Session 19. Summary of course
3. One to one session with nurse
Session covers:
• Classification assessment with headache diary
• Discussion around medication
• Lifestyle factors and personalised goal setting.
The outcomes from our development and pilot work suggest the two-day group intervention followed by a one to one consultation with the nurse and relevant telephone follow-up is feasible and acceptable to a chronic headache population after the recommended changes were applied. Our training package (after the addition of a third day) is sufficient to support facilitators in developing the relevant knowledge base and confidence in facilitating groups.
The development process has mapped onto the MRC framework for developing complex interventions as well as being guided by a Person-Based Approach and core theoretical principles from psychological models and behaviour change theory. We have taken into account the views and input from a range of stakeholders including clinicians, healthcare professionals, academics, patients and charity partners throughout the intervention planning, design and implementation phases.
This work has some potential weaknesses, the number of participants and facilitators was small and we might not have been able to capture the full range of experience in our qualitative work. However, our experience was that no new themes were emerging once interviews were complete. We have not evaluated the revised package before implementing this in the main trial; although the opportunity exists to make minor adjustments following the internal pilot. It is disappointing that we were not able to include lay facilitators but our experience was, that for this study, this was simply not practical.
The PPI element has been an important part of the intervention development process and a particular strength of this work. Our PPI partners have guided us to develop something that is acceptable and relevant for this clinical population. Our early work and the involvement of our PPI partners has allowed us to identify the needs of this population, explore the opportunity to map existing strategies from other interventions, identify any barriers and facilitators to change and subsequently identify appropriate behaviour change techniques to enable implementation of more desired behaviours for the long-term.
The process of developing the intervention to provide a manualised package for use in our definitive randomised controlled trial has been a lengthy process. Despite this, we have produced an intervention that is grounded in the needs of people living with chronic headaches as well as the theory and evidence base.
As part of the intervention development we have also considered quality assurance. For the main RCT the quality, accuracy and approach to delivery are observed and facilitators are provide with feedback. Observations are conducted by members of the study team who are familiar with the intervention. In addition to this, we encourage personal reflection from facilitators via email recording their thoughts and feelings about the sessions, noting things that went well and where things could have gone better. These emails help the intervention design team best support facilitators.
The CHESS education and self-management intervention is currently being tested in a randomised controlled trial aiming to look at the clinical and cost-effectiveness. We anticipate publishing final results in 2021.
- 1.
In 2018 Migraine Action merged with the Migraine Trust - https://www.migrainetrust.org/
The manuscript was written on behalf of the CHESS co-applicants, study team and PPI representatives.
Professor Martin Underwood
Chief Investigator
Warwick Medical School – University of Warwick
Dr Felix Achana
Senior Research Fellow (Health Economics)
Warwick Medical School – University of Warwick
Dr Dawn Carnes
Co Applicant
Queen Mary University London
Dr Brendan Davies
Co Applicant
Royal Stoke University Hospital
Professor Sandra Eldridge
Co Applicant
Queen Mary University London
Dr David Ellard
Co Applicant
Warwick Medical School – University of Warwick
Professor Frances Griffiths
Co Applicant
Warwick Medical School – University of Warwick
Dr Kirstie Haywood
Co Applicant
Warwick Medical School – University of Warwick
Dr Siew Wan Hee
Co Applicant
Warwick Medical School – University of Warwick
Dr Manjit Matharu
Co Applicant
National Hospital for Neurology & Neurosurgery
Dr Dipesh Mistry
Senior Research Fellow (Statistics)
Warwick Medical School – University of Warwick
Dr Hema Mistry
Co Applicant
Warwick Medical School – University of Warwick
Mrs Vivien Nichols
Research Fellow
Warwick Medical School – University of Warwick
Professor Stavros Petrou
Co Applicant
Warwick Medical School – University of Warwick
Dr Shilpa Patel
Senior Research Fellow
Warwick Medical School – University of Warwick
Professor Tamar Pincus
Co Applicant
Royal Holloway
Dr Rachel Potter
Senior Research Fellow
Warwick Medical School – University of Warwick
Dr Harbinder Sandhu
Co Applicant
Warwick Medical School – University of Warwick
Professor Stephanie Taylor
Co Applicant
Queen Mary University London
Charity partners
Co Applicants (PPI)
The National Migraine Centre, The Migraine Trust, Migraine Action
CHESS study teams
Trial management
University of Warwick &
Queen Mary University London
This work presents independent research funded by the National Institute for Health Research (NIHR) under the Programme Grants for Applied Research programme [project number RP-PG-1212-20018]. The views expressed in this work are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Authors' contributions
SP – Designed the intervention, trained the facilitators and produced first draft of the manuscript. RP – supported the intervention design and training, provided critical revisions to the manuscript. MSM - supported the intervention design and training, provided critical revisions to the manuscript. DC – supported the intervention design, provided critical revisions to the manuscript. SJT - supported the intervention design, provided critical revisions to the manuscript. VN - supported the intervention design, provided critical revisions to the manuscript. TP - supported the intervention design, provided critical revisions to the manuscript. MU – conceived the original study design, supported intervention design and training, provided critical revisions to the manuscript. HS – Supported intervention design and training, provided critical revisions to the manuscript. All authors have read and approved the final manuscript.
Ethics approval and consent to participate
Ethics approval was given on the 17th Of February 2017 by North West - Greater Manchester East Research Ethics Committee (REC REF: 16/NW/0890). Written consent was taken for participation.
Consent for publication
Not applicable.
Competing interests
SP and HS are directors of Health Psychology Services Ltd. which in part provides psychological treatments for those with chronic pain.
MSM serves on the advisory board for Allergan, Medtronic, Novartis and TEVA and has received payment for the development of educational presentations from Allergan, electroCore, Medtronic, Novartis and TEVA.
SJCT was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust.
MU is a director and shareholder of Clinvivo Ltd. Use of this company was specified in original application to funding to NIHR. MU has recused himself from all subsequent discussions regarding the use of the App in this study. All contracting processes have been in accord with University of Warwick financial regulations.
MU was Chair of the NICE accreditation advisory committee until March 2017 for which he received a fee. He is chief investigator or co-investigator on multiple previous and current research grants from the UK National Institute for Health Research, Arthritis Research UK and is a co-investigator on grants funded by Arthritis Australia and Australian NHMRC. He has received travel expenses for speaking at conferences from the professional organisations hosting the conferences He is part of an academic partnership with Serco Ltd. related to return to work initiatives. He is a co-investigator on a study which receives support in kind from Orthospace Ltd. He is an editor of the NIHR journal series, and a member of the NIHR Journal Editors group for which he receives a fee. He has published multiple papers on chronic pain some of which are referenced in this paper.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.


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Small GIANTS Conference | February 17, 2016
February 17, 2016 | Champions Club, Lincoln, NE
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I love photographing this family! I've gotten to know mom and dad through mutual friends and always enjoy catching up with them. Sis always gives me big hugs when she sees me and just loves getting her picture taken. She's a photographer's dream. Little bro had to be bribed (several times!) but it was nothing that a half a dozen apple cider donuts couldn't fix 😉 Read More
A beautiful fall family session. It was cold out but we braved the wind and the chill in the air and got some nice shots. Read More
There is no bigger compliment a photographer can receive than repeat clients. I had the pleasure of photographing this family last Fall and this time was just as fun!!
I am already excited about the next time I get to photograph these three beautiful sisters and their gorgeous mama. We might even let daddy get in a few shots next time:) Read More
I loved capturing the cute smiles his special day brought to his face. Guess what he wants to be when he grows up? <3 Read More
This beautiful family of three recently became a family of four. Kelli contacted me through Facebook almost six months ago and it wasn't until a couple of days before the shoot that we found out we were practically neighbors. How awesome is that!?! I can't wait to get to know them better!
We had a great time the morning of the shoot and I love that we were able to take some pictures right in front of their home. I can just picture the same scene 10 years from now with the girls all grown…sigh… Read More
A few of my favorites from a wedding I second-shot for Dani Leigh Photography in Spring 2015. Read More
I adore how much Kyla and Todd's love for one another shows; in person and in the pictures! Its genuine and inspiring. This year, the couple celebrates their 10th wedding anniversary! And what better way to commemorate this special occasion than with pictures. We met early Saturday morning; all the while 30 something family members were gathering for a surprise anniversary party Kyla had planned for Todd. He had no idea! Everything went as planned and the couple celebrated in style with their friends and family and two beautiful children. Here's to another 10 years guys…and 10 after that…and 10 after that… Read More
Please enjoy a couple of my favorite shots from another fun and creatively styled photographer 'shoot-out' by Liz Hough. Baby H who is 5 days new here was so good while a group of photographers were circling around just shooting away. Read More
I recently had the pleasure to work with one of the most positive and cheerful people I've ever met. Her name is Julie Reisler and she's out to conquer the world with her powerful message of self-awareness. She is a health and wellness coach and an encourager of others. She's an all-around cheerleader and one you want cheering for you! We had so much fun together creating a gallery of professional headshots and stock images for use on her new website (http://juliereisler.com/). We literally spent hours together without even realizing how much time had passed. The sun set and finally concluded our session. It was crazy! Hope you enjoy a few of my favorites from this day! Read More
I had a blast exploring Napa Valley with these two love birds. They are getting married next year and I couldn't be happier for them. Congrats on your engagement Jeremy & Mary! You guys are sooooo in love and it shows! I wish you guys all the best and thank you for allowing me to capture your engagement pictures. Read More
I loved everything about this Carroll Creek wedding in Frederick, Maryland. It was a beautiful *HOT* day, but considering how inconsistent the weather had been around this time, we were happy it wasn't raining. The couple met on the creek so the location for their wedding couldn't have been more appropriate! They were surrounded by their closest family and friends and I was so happy to be a part of their special day. Read More
This is it! My first wedding second shooting for Dani Leigh Photography! I could not have asked for a better mentor to learn from. She is fun, helpful, and possesses a wealth of knowledge that she is not afraid to share. There were many lessons learned from this first experience, but you never stop learning so I anticipate every experience will be just that; another amazing learning opportunity. Read More
I enjoyed exploring historic New Market with Rich for his professional headshots. As a portrait photographer, I take great pleasure in capturing professional images with a natural and realistic representation of the person's individuality. Business casual, yet credible and professional. I think my friend Rick here nailed it!! Read More
I've known Amanda since 2010 when she was just a newlywed. She is now going to be a mother of two. She is a beautiful wife, mother and friend and I wish her all the best as she continues to grow her beautiful family. Read More
It was a beautiful day for Spring mini sessions in Frederick, MD. This family was the last of the day and got the most beautiful light right at sunset. We had so much with posing and just laughed the whole time. Read More
I had an absolute blast with this wonderful little family. We planned a casual get-together one random Saturday, and boom, this happens! I mean, I might have coincidentally suggested they coordinate their attire, and I might have coincidentally planned the play-date around sunset (my FAVORITE time of day to shoot), and I might have coincidentally had my camera charged and ready to go. Just saying. Things happen! Read More


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Common Signs That Your Home's Air Conditioner Is About To Fail
During the heat of the summer, many homeowners rely on their air conditioner around the clock to keep their home at a cool and comfortable temperature. Unfortunately, HVAC units don't last forever, and you will eventually need to replace yours. No one wants their air conditioner to fail completely on a hot summer day, so it is important to know the signs of a failing HVAC unit so you can make plans to have it replaced. Some common signs that your home's air conditioner has reached the end of its lifespan include:
Increasing Bills
As an HVAC unit ages, it can no longer run as efficiently as it used to. Thus, it may run longer and cycle on and off more often in order to keep your home cool. When your air conditioner has to run longer and more often, you will likely see an increase in your electricity bill during the summer months. If you notice a big spike in the cost to cool your home, it often means that your air conditioner is on its last legs and needs to be replaced with a new unit.
Constant Problems
In many cases, air conditioning units quit working properly out of nowhere. When an HVAC unit is near the end, you will problem begin to notice that it has a number of problems that need repair by a professional HVAC technician. Getting your air conditioner repaired is not cheap, and if you're experiencing constant problems it usually means that your air conditioner is on the way to failure. Instead of pouring money into having your air conditioner fixed, it is a better idea to put that cash towards buying a new HVAC unit.
Lack of Cool Air
When an air conditioner no longer works properly, you will most likely notice that the air being forced into your home is not as cool as it used to be. This can make your home uncomfortably warm during the summer when you're trying to escape the heat. You can have your air conditioner checked out by an HVAC company, but if your A/C is very old, the components of the appliance are probably worn out and can no longer create very cool air for your home.
Strange Noises
As an HVAC unit begins to fail, you may notice strange sounds from the outside unit. These noises can sound like clanging, screeching, whining, or banging. Strange sounds from your HVAC unit are never a good thing, and you should consider checking out the price to buy a new HVAC unit and have it installed.
Contact local HVAC services for more information and assistance.


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Hello everyone! Today I have some tombstone nails to share! I used a frankened dark gray polish, then Wet 'n Wilds matte top coat, then black acrylic paint to hand paint the lettering and crosses.
I tried to add texture to it by dabbing a sponge on it before it all dried and by using a stiff brush to stipple it but it kept leveling back out...go figure...the one time I need it to wrinkle and not self level is the one time it behaves like nail polish should!
I think the Wet 'n Wild isn't really a matte but more of a satin finish but I'm out of all my other matte top coats so I had to make do. It turned out all right...maybe...¯\_(ツ)_/¯
It's definitely a Halloween mani...and that's about it, lol! Sometimes you don't always knock it out of the park but I love sharing my attempts regardless of how they turn out, especially since it will give me something to look back on in later years and see how much I've improved! Thanks for looking and check back soon for my next spooky mani!


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You have several reasons to pick French Door Local Experts when it comes to French Doors in Roxbury, KS. Our supplies are of the very best quality, our money saving practices are practical and powerful, and our customer service ratings cannot be topped. We understand your requirements and objectives, and we are ready to serve you using our practical experience. Call 888-669-5583 when you require French Doors in Roxbury, and we're going to work with you to successfully finish your job.


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