Measures of function in low back pain/disorders: Low Back Pain Rating Scale (LBPRS), Oswestry Disability Index (ODI), Progressive Isoinertial Lifting Evaluation (PILE), Quebec Back Pain Disability Scale (QBPDS), and Roland-Morris Disability Questionnaire (RDQ)

Including patient-reported outcomes and patient-reported resource-use questionnaires in studies

RATIONALE

More efficient and better informed healthcare systems are expected to have improved knowledge of the impact of interventions on patient outcomes and resources used by patients and providers in specific health conditions.

OBJECTIVES

To describe trends related to putting patients at the center of healthcare decision making, regulatory trends and best practice recommendations for developing high-quality patient-reported outcomes (PROs), and strategic issues related to including PROs in studies.

MATERIALS AND METHODS

We summarize PRO concepts, definitions, and broadly-accepted scientific standards for developing, assessing, and interpreting PROs. Three conceptual models are presented as examples for assessing PROs in relation to other outcomes. We discuss different perspectives for stakeholders, including regulatory issues pertaining to formal guidance for PRO development and for use in trials. We provide examples of PROs used in studies for assessing health outcomes in oncology and resource-use outcomes in low back pain patients.

RESULTS

Psychometric scientists working closely with multi-disciplinary teams and regulatory authorities have greatly improved the science of collecting, assessing, and understanding patient-reported outcomes in clinical trials. A simplified framework is presented for strategic considerations for including PROs in studies, such as the appropriate timing for PRO endpoints. Asking patients about their health status and/or use of resources improves our understanding of how interventions and care processes may impact their lives and their budgets. We provide examples from a back pain trial of patient-reported resource-use questionnaires for medicines taken and other services or products used by patients.

CONCLUSIONS

Healthcare stakeholders are placing increased emphasis on resource use and the impact of interventions on patients, including effects associated with diagnostic tests. Patient-reported outcomes are being used in clinical practice and in clinical research, supported by formal best-practice guidelines. Radiology has a role as an engaged stakeholder in the design, conduct, and interpretation of patient-based evidence, and in its relevance to health policy implementation.

Responsiveness and interpretability of the Portuguese version of the Quebec Back Pain Disability Scale in patients with chronic low back pain

STUDY DESIGN

A prospective cohort study with a 6-week follow-up of patients with chronic low back pain undergoing physiotherapy.

OBJECTIVE

To examine the responsiveness of the Portuguese version of the Quebec Back Pain Disability Scale (QBPDS-PT), and to determine the minimal clinically important difference, minimal detectable change (MDC), and floor/ceiling effects.

SUMMARY OF BACKGROUND DATA

Measuring change over time is critical to assess the effectiveness of a physiotherapy intervention or to distinguish individual differences in response to treatment.

METHODS

One hundred thirty-two patients were recruited from 16 outpatient clinics in 7 different regions of Portugal. A final sample of 120 patients completed the QBPDS-PT twice: at the baseline and after 6 weeks of physiotherapy treatment. The patient global impression of change scale was used as an external criterion measure to distinguish between improved or nonimproved patients' scores between baseline and follow-up. The responsiveness of the QBPDS-PT was assessed through correlation coefficient and receiver operating characteristics curves. The minimal clinically important difference was estimated by the receiver operating characteristics curve method and the MDC through the standard error of measurement.

RESULTS

The scale revealed moderate responsiveness (ρ = 0.426 and area under the curve = 0.741; 95% confidence interval: 0.645-0.837). The MDC achieved 19 points, whereas the minimal clinically important difference was found to be 6.5 points (area under the curve = 0.741, sensitivity = 72%, specificity = 71%). A floor effect was founded with 15.8% of the participants reporting values within the MDC at the lower end of the available range of scores. For the highest baseline scores of QBPDS-PT (≥34 points) the optimal cutoff point was found to be 10.5 points (area under the curve = 0.738, sensitivity = 73%, specificity = 67%).

CONCLUSION

The QBPDS-PT demonstrated moderate levels of responsiveness, and is recommended to measure change in disability in patients with chronic low back pain after physiotherapy intervention.

LEVEL OF EVIDENCE

N/A.

Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: a systematic review and meta-analysis

OBJECTIVES

Musculoskeletal conditions (MSCs) are the leading cause of disability and chronic pain in the developed world, impacting both functional ability and psychosocial health. The current review investigates the effectiveness of yoga on primary outcomes of functional ability, pain and psychosocial outcomes across a range of MSCs.

METHODS

A comprehensive search of 20 databases was conducted for full-text, randomized controlled trials of yoga in clinically diagnosed MSCs.

RESULT

Seventeen studies met the inclusion criteria, involving 1,626 participants with low back pain (LBP), osteoarthritis (OA), rheumatoid arthritis (RA), kyphosis or fibromyalgia. Studies were quality rated, and analysed for the effect of yoga on primary outcomes, immediately post-intervention. Twelve studies were rated as good quality. Yoga interventions resulted in a clinically significant improvement in functional outcomes in mild-to-moderate LBP and fibromyalgia, and showed a trend to improvement in kyphosis. Yoga significantly improved pain in OA, RA and mild-to-severe LBP. Psychosocial outcomes were significantly improved in mild-to-moderate LBP and OA. Meta-analysis of good-quality studies showed a moderate treatment effect for yoga of -0.64 (95%CI -0.89 to -0.39) for functional outcomes and -0.61 (95%CI -0.97 to -0.26) for pain outcomes.

CONCLUSIONS

Evidence suggests that yoga is an acceptable and safe intervention, which may result in clinically relevant improvements in pain and functional outcomes associated with a range of MSCs. Future analysis of outcomes which take into account the amount of yoga received by participants may provide insight into any putative duration or dosage effects of yoga interventions for MSCs.

Do more MRI findings imply worse disability or more intense low back pain? A cross-sectional study of candidates for lumbar disc prosthesis

OBJECTIVE

To examine whether combined magnetic resonance imaging (MRI) findings are related to the degree of disability and low back pain (LBP) in candidates for lumbar disc prosthesis surgery.

MATERIALS AND METHODS

This cross-sectional study included 170 disc prosthesis candidates (mean age 41 years; 88 women) with chronic non-radicular LBP and localized disc degeneration. Experienced radiologists rated Modic changes and disc findings at L4-S1 on pre-treatment MRIs. An MRI total score (0-10) for findings at L4/L5 plus L5/S1 was calculated for Modic type I and/or II changes, a posterior high intensity zone (HIZ) in the disc, dark/black nucleus pulposus signal, and ≥40 % disc height decrease. We analyzed the relationship of the MRI total score to the Oswestry Disability Index (ODI) (n = 170) and LBP intensity scores (0-100 visual analogue scale, n = 165) using multiple linear regression and adjusting for age, gender, body mass index, smoking, and anxiety/depression.

RESULTS

The MRI total score was not related to ODI (regression coefficient 0.12, p = 0.79) or LBP intensity (regression coefficient 0.64, p = 0.37). When individual MRI findings were analyzed, patients with HIZ at L5/S1 had slightly lower ODI scores (4.7 points, p = 0.02). In post hoc analyses, results remained unchanged after adding facet arthropathy to the MRI total score and adjusting also for physical workload and physical leisure-time activity.

CONCLUSIONS

The combined MRI findings were not related to the degree of disability or the intensity of LBP. These degenerative MRI findings cannot explain variation in pre-treatment disability and pain in patients with chronic LBP accepted for disc prosthesis surgery.

Cross-cultural adaptation and validation of the Quebec Back Pain Disability Scale to European Portuguese language

STUDY DESIGN

Cross-cultural adaptation and psychometric testing.

OBJECTIVE

To conduct the cross-cultural adaptation of the Quebec Back Pain Disability Scale (QBPDS) and investigate its reliability and validity in patients with chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA

The QBPDS is one of the most commonly used scales to evaluate functional incapacity resulting from low back pain. Although measuring disability is an important outcome in physiotherapy care, there is no previous research relating to the cultural adaptation and psychometric testing of the QBPDS in the Portuguese-speaking population.

METHODS

The questionnaire was first translated and back-translated in accordance with the published guidelines. The Portuguese version of the QBPDS was then pilot tested in a Portuguese sample of 40 patients with CLBP. Psychometric properties were evaluated in a new sample of 132 patients with CLBP. Exploratory factor analysis was performed to confirm its unidimensionality. Reliability was evaluated through internal consistency and reproducibility, using the Cronbach α and intraclass correlation coefficient, respectively. Construct validity was assessed with correlations between the QBPDS and the Roland-Morris Disability Questionnaire and between the QBPDS and the visual analogue pain scale for convergent validity and pain localization for discriminative validity, using the Spearman correlation analysis and the Mann-Whitney test.

RESULTS

Exploratory factor analysis revealed the existence of one major factor that explains 52.1% of the variance. One-week test-retest reliability was 0.7, and internal consistency was 0.95. The QBPDS correlated strongly with the Roland-Morris Disability Questionnaire (0.62; P < 0.001), moderately with pain (0.38; P < 0.001), and shows capability to discriminate between patients with localized and referred pain (U = 1218; P < 0.0005).

CONCLUSION

The reliability and construct validity of the Portuguese version of the QBPDS are acceptable to assess functional status of Portuguese-speaking patients with CLBP. .

Validation of a French version of Roland-Morris questionnaire in chronic low back pain patients

OBJECTIVE

To validate a French version of the Roland-Morris Disability Questionnaire (RMDQ) in patients with chronic low back pain (LBP).

MATERIAL AND METHODS

Fifty-eight patients due to participate in a functional rehabilitation programme for chronic low back pain were included prospectively. The RMDQ, the Quebec Back Pain Disability Scale (QBPDS) and the "daily activities" subscale of the Dallas Pain Questionnaire (DPQ) were administered. The RMDQ was assessed for internal consistency, reliability, criterion validity and sensitivity to change.

RESULTS

Cronbach's alpha for the RMDQ was 0.84. The intraclass correlation coefficient [95% confidence interval] was 0.89 [0.83-0.93]. The RMDQ score was correlated with the QBPDS score (r=0.713) and the DPQ's "daily activities" subscore (r=0.514). The results of assessments before and after functional rehabilitation showed that the French version of the RMDQ had very high sensitivity to change (effect size: 1.49) and was more sensitive than the QBPDS and the DPQ's "daily activities" subscore.

CONCLUSIONS

Our study validated the French version of the RMDQ in patients suffering from chronic low back pain. Furthermore, we highlighted the questionnaire's very high sensitivity to change.

A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial

BACKGROUND

Lumbar facet joint degeneration is a source of chronic low back pain, with an incidence of 15% to 45% among patients with low back pain. Various therapeutic techniques in the treatment of facet-related pain have been described in the literature, including intraarticular lumbar facet joint steroid injections and radiofrequency denervation. In this study, we compared the effectiveness of intraarticular facet joint steroid injections and radiofrequency denervation.

METHODS

Our randomized, double-blind, controlled study included patients who received intraarticular steroid infiltrations in the lumbar facet joints (L3/L4-L5/S1) and patients who underwent radiofrequency denervation of L3/L4-L5/S1 segments. The inclusion criteria were based first on magnetic resonance imaging findings showing hypertrophy of the facet joints L3/L4-L5/S1 and a positive response to an intraarticular test infiltration of the facet joints L3/L4-L5/S1 with local anesthetics. The primary end point was the Roland-Morris Questionnaire. Secondary end points were the visual analog scale and the Oswestry Disability Index. All outcome assessments were performed at baseline and at 6 months.

RESULTS

Fifty-six patients were randomized; 24 of 29 patients in the steroid injection group and 26 of 27 patients in the denervation group completed the 6-month follow-up. Pain relief and functional improvement were observed in both groups. There were no significant differences between the 2 groups for the primary end point (95% confidence interval [CI], -3 to 4) and for both secondary end points (95% CI for visual analog scale, -2 to 1; 95% CI for Oswestry Disability Index, -18 to 0).

CONCLUSIONS

Intraarticular steroid infiltration or radiofrequency denervation appear to be a managing option for chronic function-limiting low back pain of facet origin with favorable short- and midterm results in terms of pain relief and function improvement, but improvements were similar in both groups.

Electrical stimulation for chronic non-specific low back pain in a working-age population: a 12-week double blinded randomized controlled trial

Background

Non-invasive electrotherapy is commonly used for treatment of chronic low back pain. Evidence for efficacy of most electrotherapy modalities is weak or lacking. This study aims to execute a high-quality, double-blinded randomized controlled clinical trial comparing 1) H-Wave® Device stimulation plus usual care with 2) transcutaneous electrical nerve stimulation (TENS) plus usual care, and 3) Sham electrotherapy plus usual care to determine comparative efficacy for treatment of chronic non-specific low back pain patients.

Methods/Design

Patients- Chronic non-specific low back pain patients between ages of 18–65 years, with pain of at least 3 months duration and minimal current 5/10 VAS pain. Patients will have no significant signs or symptoms of lumbosacral nerve impingement, malignancy, spinal stenosis, or mood disorders.

Study design- Double blind RCT with 3 arms and 38 subjects per arm. Randomization by permuted blocks of random length, stratified by Workers Compensation claim (yes vs. no), and use of opioids. The null hypothesis of this study is that there are no statistically significant differences in functional improvement between treatment types during and at the end of a 12-week week treatment period.

Data collection- Subjective data will be collected using Filemaker Pro™ database management collection tools. Objective data will be obtained through functional assessments. Data will be collected at enrollment and at 1, 4, 8, and 12 weeks for each participant by a blinded assessor.

Interventions- H-Wave® device stimulation (Intervention A) plus usual care, transcutaneous electrical nerve stimulation (TENS) (Intervention B) plus usual care, and sham electrotherapy plus usual care (control). Each treatment arm will have identical numbers of visits (4) and researcher contact time (approximately 15 hours).

Outcomes- Primary outcome measure: Oswestry Disability Index. Secondary measures include: Rowland Morris Instrument, VAS pain score, functional evaluation including strength when pushing and pulling, pain free range of motion in flexion and extension. Outcome measures assessed at baseline, 1, 4, 8, and 12 weeks. Treatment failure will be defined if patient terminates assigned treatment arm for non-efficacy or undergoes invasive procedure or other excluded cointerventions. Data will be analyzed using intention-to-treat analysis and adjusted for covariates related to LBP (e.g. age) as needed.

Discussion

Study strengths include complex randomization, treatment group allocation concealment, double blinding, controlling for co-interventions, rigorous inclusion criteria, assessment of compliance, plans for limiting dropout, identical assessment methods and timing for each treatment arm, and planned intention-to-treat analyses.