A method for scoring the pain map of the McGill Pain Questionnaire for use in epidemiologic studies

Investigating the relationship between body structure status, work activity type, and the prevalence of musculoskeletal disorders among detergent industry workers

BACKGROUND

The physical condition of workers' body structure and assigned duties, can contribute to the prevalence of musculoskeletal disorders.

OBJECTIVE

This study aimed to investigate the relationship between body structure status, type of work activity, and the prevalence of musculoskeletal disorders among workers in the detergent industry.

METHODS

This cross-sectional study involved 148 industrial workers selected based on inclusion criteria and their medical checkup records. Data collection for the study included a demographic information questionnaire, a body map questionnaire, and an assessment of the workers' musculoskeletal system conducted by three physiotherapists simultaneously.

RESULTS

54.1% of the participants had a total body structure score classified as poor or fair. The neck region showed the highest prevalence of musculoskeletal disorders (51.4%), followed by the lower back region (35.1%). Significant associations were found between abnormalities in the upper and middle limbs of the body and the prevalence of pain in the right shoulder region (Fisher/F = 9.29, P≤0.05) as well as the intermediate back region (F = 10.28, P≤0.01). Office workers experienced a higher prevalence of neck pain than workers in the product line and technical roles, with a statistically significant Odds Ratio (OR) ranging between 2.7 and 6.6 times. Conversely, industrial workers who operate powered machinery showed a higher prevalence of pain in the left shoulder (OR = 3.93) and left foot (OR = 4.07). Meanwhile, workers involved in loading and unloading tasks had a higher prevalence of pain in the middle back (OR = 3.61) and right foot (OR = 4.5) compared to office workers.

CONCLUSIONS

The prevalence of pain in the right shoulder and middle back may be due to abnormalities in the upper and intermediate body structure. Production line workers reported a higher prevalence of pain in the left shoulder, middle back, and foot compared to office workers.

Gait and Axial Spondyloarthritis: Comparative Gait Analysis Study Using Foot-Worn Inertial Sensors

Background

Axial spondyloarthritis (axSpA) can lead to spinal mobility restrictions associated with restricted lower limb ranges of motion, thoracic kyphosis, spinopelvic ankylosis, or decrease in muscle strength. It is well known that these factors can have consequences on spatiotemporal gait parameters during walking. However, no study has assessed spatiotemporal gait parameters in patients with axSpA. Divergent results have been obtained in the studies assessing spatiotemporal gait parameters in ankylosing spondylitis, a subgroup of axSpA, which could be partly explained by self-reported pain intensity scores at time of assessment. Inertial measurement units (IMUs) are increasingly popular and may facilitate gait assessment in clinical practice.

Objective

This study compared spatiotemporal gait parameters assessed with foot-worn IMUs in patients with axSpA and matched healthy individuals without and with pain intensity score as a covariate.

Methods

A total of 30 patients with axSpA and 30 age- and sex-matched healthy controls performed a 10-m walk test at comfortable speed. Various spatiotemporal gait parameters were computed from foot-worn inertial sensors including gait speed in ms^–1 (mean walking velocity), cadence in steps/minute (number of steps in a minute), stride length in m (distance between 2 consecutive footprints of the same foot on the ground), swing time in percentage (portion of the cycle during which the foot is in the air), stance time in percentage (portion of the cycle during which part of the foot touches the ground), and double support time in percentage (portion of the cycle where both feet touch the ground).

Results

Age, height, and weight were not significantly different between groups. Self-reported pain intensity was significantly higher in patients with axSpA than healthy controls (P<.001). Independent sample t tests indicated that patients with axSpA presented lower gait speed (P<.001) and cadence (P=.004), shorter stride length (P<.001) and swing time (P<.001), and longer double support time (P<.001) and stance time (P<.001) than healthy controls. When using pain intensity as a covariate, spatiotemporal gait parameters were still significant with patients with axSpA exhibiting lower gait speed (P<.001), shorter stride length (P=.001) and swing time (P<.001), and longer double support time (P<.001) and stance time (P<.001) than matched healthy controls. Interestingly, there were no longer statistically significant between-group differences observed for the cadence (P=.17).

Conclusions

Gait was significantly altered in patients with axSpA with reduced speed, cadence, stride length, and swing time and increased double support and stance time. Taken together, these changes in spatiotemporal gait parameters could be interpreted as the adoption of a so-called cautious gait pattern in patients with axSpA. Among factors that may influence gait in patients with axSpA, patient self-reported pain intensity could play a role. Finally, IMUs allowed computation of spatiotemporal gait parameters and are usable to assess gait in patients with axSpA in clinical routine.

Trial Registration

ClinicalTrials.gov NCT03761212; https://clinicaltrials.gov/ct2/show/NCT03761212

International Registered Report Identifier (IRRID)

RR2-10.1007/s00296-019-04396-4

From Paper to Digital Applications of the Pain Drawing: Systematic Review of Methodological Milestones

Background

In a pain drawing (PD), the patient shades or marks painful areas on an illustration of the human body. This simple yet powerful tool captures essential aspects of the subjective pain experience, such as localization, intensity, and distribution of pain, and enables the extraction of meaningful information, such as pain area, widespreadness, and segmental pattern. Starting as a simple pen-on-paper tool, PDs are now sophisticated digital health applications paving the way for many new and exciting basic translational and clinical applications.

Objective

Grasping the full potential of digital PDs and laying the groundwork for future medical PD apps requires an understanding of the methodological developments that have shaped our current understanding of uses and design. This review presents methodological milestones in the development of both pen-on-paper and digital PDs, thereby offering insight into future possibilities created by the transition from paper to digital.

Methods

We conducted a systematic literature search covering PD acquisition, conception of PDs, PD analysis, and PD visualization.

Results

The literature search yielded 435 potentially relevant papers, from which 53 methodological milestones were identified. These milestones include, for example, the grid method to quantify pain area, the pain-frequency maps, and the use of artificial neural networks to facilitate diagnosis.

Conclusions

Digital technologies have had a significant influence on the evolution of PDs, whereas their versatility is leading to ever new applications in the field of medical apps and beyond. In this process, however, there is a clear need for better standardization and a re-evaluation of methodological and technical limitations that no longer apply today.

Gait as predictor of physical function in axial spondyloarthritis: the prospective longitudinal FOLOMI (Function, Locomotion, Measurement, Inflammation) study protocol

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease affecting predominantly sacroiliac joints and axial skeleton. axSpA progression being irregular and hardly predictable, identifying functional decline is particularly important in patient with axSpA to allow delivery of timely and targeted interventions. Pain, reduced range of motion or altered posture can have adverse consequences on gait. Although gait has previously been used as a sensitive measure of physical outcomes in elderly and pathological populations, to the best of our knowledge, no study has used gait as a predictor of physical function in patients with axSpA. The objective of our study is hence to determine if gait parameters measured in patients with axSpA could predict the evaluation at 18 months of physical function as assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI). This is a prospective and longitudinal study. Sixty patients with axSpA and 30 healthy age- and sex-matched controls will be included. Patients should be aged 18-65 years at time of their first evaluation, followed at Grenoble Alpes University Hospital for axSpA or ankylosing spondylitis, able to walk 180 m without technical help and with stable treatment for at least 12 months. Clinical characteristics, BASFI, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), clinical and laboratory measurements of gait will be assessed during four visits (at baseline and at months 6, 12, and 18). Similar assessments will be performed once for the healthy control group. A linear mixed model at 6, 12 and 18 months will be constructed to answer to the first objective, with the BASFI as dependent variable and gait parameters as explanatory variables. The data collection started in August 2018 and will be completed with the inclusion and follow-up of all the participants. We believe that the combination of clinical and laboratory measurements of gait in patients with axSpA could strengthen the capacity to monitor disease's evolution and to predict changes in patients' physical function. Results of the present study could ultimately allow delivering targeted, timely, personalized interventions and treatment in patients with axSpA.Trial registration: The study was approved by local ethic committee (CPP Ile De France 1, RCB: 2017-A03468-45, date of agreement: July 17th, last version: V4.0, 2018, March 5th, 2019) and is retrospectively registered in Clinical trials (NCT03761212).

From Paper to Digitalized Body Map: A Reliability Study of the Pain Area

BACKGROUND

Computerized methods to analyze pain drawings (PDs) have been developed and may aid to measure the pain area more precisely.

OBJECTIVE

The aim of this study was to verify whether examiners can reproduce the patient's PDs with acceptable reliability.

METHODS

This was an intra-rater and inter-rater reliability study. The protocol consisted of 4 steps: (1) scanning of paper PDs; (2) sharing the digitalized PD images between examiners; (3) reproducing the PD images in the sketching application; and (4) calculating the pain area in pixels and percentages. We calculated intraclass correlation coefficients (ICCs; 2,1), the standard error of the measurement (SEM), and the smallest detectable difference (SDD).

RESULTS

Reliability was tested using 31 PDs from 17 patients in our database (11 female [64.7%], mean age: 53.23 ± 11.57 years). Intra-rater reliability varied from ICC (2,1) = 0.991 (95% confidence interval [CI] = 0.982 to 0.996; SEM = 3,432.45; SDD = 162.39 pixels; P < 0.001) to ICC (2,1) = 0.992 (95% CI = 0.978 to 0.997; SEM = 3,412.96; SDD = 161.93 pixels; P < 0.001). Inter-rater reliability for the measurement between all examiners was considered excellent (ICC [2,1] = 0.976; 95% CI = 0.956 to 0.987; SEM =8,580.75; SDD = 256.76 pixels; P < 0.001), being higher between Examiners A and C (ICC [2,1] = 0.970; 95% CI = 0.936 to 0.986; SEM = 6,453.34; SDD = 222.67 pixels; P < 0.001).

CONCLUSION

Our results show that intra- and inter-rater reliabilities were excellent when an examiner reproduced the paper PDs into digitalized PDs. This process gives clinicians and researchers the opportunity to analyze pain extent more precisely using a computerized method.

Endoscopic meatus scoring scale versus sniff test to predict insertability before transnasal endoscopy: A prospective, randomized study

BACKGROUND AND AIM

Sniff test is a common method before unsedated transnasal esophago-gastro-duodenoscopy (UT-EGD) to select a nostril insertion site. Yet there is no objective method to select a more specific meatus insertion tract for anesthesia and insertion. We devised an endoscopic meatus scoring scale by anterior meatuscopy to select the most optimal meatus insertion tract. We hypothesized that meatuscopy instead of sniff test might improve tolerance and reduce adverse events during nasal anesthesia and UT-EGD.

METHODS

A prospective randomized controlled trial to compare patient tolerance and adverse events.

RESULTS

A total of 359 patients were assessed and finally 310 patients were analyzed. There were no statistical differences in patient characteristics and insertion failure rates. Pain scores during nasal anesthesia, nasal insertion/exsertion, UT-EGD, and overall tolerance were significantly lower in the meatuscopy group than sniff test group. Compared with the sniff tested patients, the meatuscopied patients had significantly lower epistaxis rates during insertion/exsertion, better visual capacity after decongestive anesthesia, and shorter total procedure time. A significantly higher proportion of the meatuscopied than sniff tested patients would like to receive the same procedure next time. Nasal discharge, nasal pain, epistaxis, and blowing out blood clots occurred significantly less frequent in the meatuscopy group than sniff test group. More sniff tested than meatuscopied patients had headache, delayed epistaxis, and sinusitis although they were not statistically significant.

CONCLUSION

Selection of an optimal meatus insertion tract by an anterior meatuscopy causes lesser nasal pain, epistaxis, and post-procedural side effects in nasal anesthesia and UT-EGD than the conventional sniff test.

Prevalence of vitamin D deficiency in chronic and subacute low back pain patients in India: a triple-arm controlled study

Vitamin D is vital for musculoskeletal health and may be associated with subacute and chronic low back pain. The objective of this study was to estimate the prevalence of vitamin D deficiency among chronic low back pain (CLBP) and subacute low back pain (SLBP), and compare the same with healthy controls. This study was designed as triple-arm case-control study comprising of CLBP, SLBP, and controls. SLBP and CLBP cases were consecutively enrolled over 3 months of winter season from November 2016 to January 2017. Serum 25- (OH) vitamin D was estimated for the study subjects and categorical comparison of severity of vitamin D deficiency was done for the cases and controls. A total of 250 CLBP, 177 SLBP cases, and 248 controls were included in the study. Mean (± SD) serum vitamin D levels among CLBP, SLBP, and controls were 20.36 (± 12.56), 21.42 (± 13.20), and 20.84 (± 6.93) ng/ml respectively, the difference being statistically insignificant. There was no significant difference in the prevalence of vitamin D deficiency among CLBP, SLBP, and controls which was 53.6, 50.8, and 51.6% respectively, in the three arms. However, the categorical analysis revealed that CLBP and SLBP cases had a significantly higher prevalence of worse categories of vitamin D deficiency. Cases had significantly larger frequency (CLBP vs. controls, 43.6 vs 20.1%, P<0.001; SLBP vs. controls, 43.5 vs 20.1%, P = 0.001) of individuals with vitamin D levels ≤ 16 ng/ml (moderate deficiency upper threshold level). Thus, the severe forms of vitamin D deficiency may be causally associated with CLBP and SLBP. The results of the present study revealed that increasing severity of vitamin D deficiency may have a pathogenetic association with chronic low back pain and subacute low back pain. These results may prove to be of significance in framing of future management guidelines for the above clinical conditions.

The Brazilian Back Complaints in the Elders (Brazilian BACE) study: characteristics of Brazilian older adults with a new episode of low back pain

OBJECTIVE

Low back pain (LBP) is little explored in the aging population especially when considering age-relevant and culturally dependent outcomes. We aimed to describe socio-demographic and clinical characteristics of Brazilian older people with a new episode of LBP presenting to primary care.

METHODS

We sourced baseline information on socio-demographic, pain-related and clinical characteristics from 602 older adults from the Brazilian Back Complaints in the Elders (Brazilian BACE) study. We analyzed differences in pain, disability, functional capacity and psychosocial factors between sub-groups based on age (i.e. participants aged 55-74 or ≥75 years), education (i.e. those with four years or less of schooling or those with more than four years of schooling) and income (i.e. participants who reported earning two or less minimal wages or three and more).

RESULTS

Participants presented severe LBP (7.18/10, SD: 2.59). Younger participants were slightly more disabled (mean difference 1.29 points, 95% confidence interval [CI]: 0.03/5.56), reporting poorer physical health, and less fall-related self-efficacy (mean difference of 2.41, 95% CI 0.35/4.46). Those less educated, and those with income equal or less than two minimum wages had more disability, pain catastrophizing and worse functional capacity.

CONCLUSIONS

This was the first study showing that Brazilian older adults with LBP present high levels of functional disability and psychological distress, especially those with low socioeconomic status.

Association of lower extremity range of motion and muscle strength with physical performance of community-dwelling older women

BACKGROUND

Reduced lower extremity range of motion (ROM) and muscle strength are related to functional disability in older adults who cannot perform one or more activities of daily living (ADL) independently. The purpose of this study was to determine which factors of seven lower extremity ROMs and two muscle strengths play dominant roles in the physical performance of community-dwelling older women.

METHODS

Ninety-five community-dwelling older women (mean age ± SD, 70.7 ± 4.7 years; age range, 65-83 years) were enrolled in this study. Seven lower extremity ROMs (hip flexion, hip extension, knee flexion, internal and external hip rotation, ankle dorsiflexion, and ankle plantar flexion) and two muscle strengths (knee extension and flexion) were measured. Physical performance tests, including functional reach test (FRT), 5 m gait test, four square step test (FSST), timed up and go test (TUGT), and five times sit-to-stand test (FTSST) were performed.

RESULTS

Stepwise regression models for each of the physical performance tests revealed that hip extension ROM and knee flexion strength were important explanatory variables for FRT, FSST, and FTSST. Furthermore, ankle plantar flexion ROM and knee extension strength were significant explanatory variables for the 5 m gait test and TUGT. However, ankle dorsiflexion ROM was a significant explanatory variable for FRT alone. The amount of variance on stepwise multiple regression for the five physical performance tests ranged from 25 (FSST) to 47% (TUGT).

CONCLUSIONS

Hip extension, ankle dorsiflexion, and ankle plantar flexion ROMs, as well as knee extension and flexion strengths may play primary roles in the physical performance of community-dwelling older women. Further studies should assess whether specific intervention programs targeting older women may achieve improvements in lower extremity ROM and muscle strength, and thereby play an important role in the prevention of dependence on daily activities and loss of physical function, particularly focusing on hip extension, ankle dorsiflexion, and ankle plantar flexion ROMs as well as knee extension and flexion strength.

Back complaints in the elders (BACE); design of cohort studies in primary care: an international consortium

Background

Although back complaints are common among older people, limited information is available in the literature about the clinical course of back pain in older people and the identification of older persons at risk for the transition from acute back complaints to chronic back pain.

The aim of this study is to assess the course of back complaints and identify prognostic factors for the transition from acute back complaints to chronic back complaints in older people who visit a primary health care physician.

Methods/design

The design is a prospective cohort study with one-year follow-up. There will be no interference with usual care. Patients older than 55 years who consult a primary health care physician with a new episode of back complaints will be included in this study.

Data will be collected using a questionnaire, physical examination and X-ray at baseline, and follow-up questionnaires after 6 weeks and 3, 6, 9 and 12 months.

The study 'Back Complaints in the Elders' (BACE) will take place in different countries: starting in the Netherlands, Brazil and Australia. The research groups collaborate in the BACE consortium. The design and basic objectives of the study will be the same across the studies.

Discussion

This consortium is a collaboration between different research groups, aiming to provide insight into the course of back complaints in older people and to identify prognostic factors for the transition from acute back complaints to chronic back complaints in older persons. The BACE consortium allows to investigate differences between older people with back complaints and the health care systems in the different countries and to increase the statistical power by enabling meta-analyses using the individual patient data. Additional research groups worldwide are invited to join the BACE consortium.

The relationship between pain and functional disability in Black and White older adults

In this study we examined pain and disability in 115 community-dwelling, urban, older adults (mean age = 74 years; 52% Black, 48% White). Participants completed a survey of pain (pain presence, intensity, locations, and duration) and disability (Sickness Impact Profile). Sixty percent of the sample reported pain; Black and White adults did not differ on any pain variable. In structural equation models controlling for socioeconomic factors and health, pain did not mediate the relationship between race and disability. Race moderated the pain-disability relationship; pain was more associated with disability among Whites than Blacks. This study highlights the need for greater understanding of health disparities between Black and White older adults as they relate to pain and disability.

Modeling impairment: using the disablement process as a framework to evaluate determinants of hip and knee flexion

Elders often present to health care providers with multiple inter-related conditions that determine an individual's ability to function. The disablement process provides a generalized sociomedical framework for investigating the complex pathways from chronic disease to disability. At each stage of the main pathway, associations may exist among primary physical factors and modifying variables that ultimately have downstream effects on the progression toward disability. The purpose of the present analysis is to examine the inter-relationships between a cohesive set of variables primarily at the level of impairment that may affect hip and knee flexion range of motion (ROM). The San Antonio Longitudinal Study of Aging enrolled 833 community dwelling Mexican (MA) and European American (EA) elders aged 64-78 years between 1992 and 1996. Of these, 647 had complete data from both a home-based and performance-based battery of assessments for these analyses. Concerning impairments, hip ROM was measured using an inclinometer, and knee ROM using a goniometer. Pain location and intensity were assessed using the McGill Pain Questionnaire. Peripheral vascular disease was assessed using doppler brachial and ankle systolic blood pressures. Ankle and knee reflexes, and vibratory sensation were assessed by a standardized neurological examination. As to diseases, diabetes was assessed using a combination of blood glucose levels and self-report, and arthritis by self-report. Concerning modifying variables, height and weight were directly measured and used to calculate BMI. Activity level was assessed with the Minnesota Leisure Time Questionnaire. Analgesic use was assessed by direct observation of medications taken within the past two weeks. We used structural equation modeling to test associations between the variables that were specified a priori. These analyses demonstrate the central role of BMI as a determinant of hip and knee flexion ROM. For an increase in level of BMI, the coefficients [SEM] for changes in levels of hip and knee ROM were -0.38 [0.05] and -0.26 [0.05], respectively. A higher BMI resulted in lower hip and knee ROM. BMI was also directly associated with prevalent diabetes (0.10 [0.05]) and arthritis (0.17 [0.05]). However, after adjustment for BMI, diabetes and arthritis did not have direct independent associations with either hip or knee ROM. BMI was also indirectly associated with knee, but not hip, ROM through paths including lower-leg pain, pain intensity, and neurosensory impairments. Diabetes had an indirect association with hip, but not knee ROM, through a path including peripheral vascular disease. In conclusion, BMI is a primary direct determinant of hip and knee ROM. The paths by which diabetes and arthritis lead to physical disability may be mediated, in part, at the level of impairment by BMI's association with joint range of motion. Interventions designed to decrease the impact of diabetes and arthritis on disability should track changes in BMI and joint ROM to measure the paths that account for the intervention's success. The observed associations suggest that interventions targeted to decrease BMI itself may lead to improved function in part through improved joint ROM.

Impact of aging on human salivary gland function: a community-based study

A comprehensive evaluation of salivary flow rates and composition was undertaken in an age- and community-stratified population. A nonmedicated subpopulation was used to assess the effect of "primary aging" on salivary gland function. Unstimulated whole, parotid and submandibular/sublingual (SMSL) saliva, as well as citrate-stimulated parotid and SMSL saliva were collected from 1006 subjects. Flow rates were determined, and the total protein concentrations measured. Height and caloric intake were documented. Subjects were divided into six age groups from 35 to 75+ years old. Significant age-related decreases in the secretion rates of unstimulated whole (p < 0.001), stimulated parotid (p < 0.01) and unstimulated and stimulated SMSL (both p < 0.0001) saliva were observed in the total population. In the non-medicated subpopulation, age-related decreases in salivary secretions were observed in unstimulated whole (p < 0.01) and unstimulated and stimulated SMSL (p < 0.01 and p < 0.0001, respectively). Multiple regression analysis revealed that, as well as age, caloric intake was related to unstimulated SMSL and stimulated SMSL saliva in the whole population, and height was a contributor to unstimulated whole saliva and unstimulated parotid saliva flow rate variances. In the non-medicated population, caloric intake was the significant independent variable for unstimulated and stimulated parotid secretion, as was height for unstimulated whole and SMSL flow rates. Age-related increases in the total protein concentration of unstimulated parotid (p < 0.001) and unstimulated SMSL (p < 0.05) saliva were evident in the whole population, but not in the non-medicated subgroup. These data suggest that there are significant age-related alterations in salivary function.

Measuring chronic rheumatic pain in Mexican Americans: cross-cultural adaptation of the McGill Pain Questionnaire

We performed a cross-cultural adaptation of the McGill Pain Questionnaire (MPQ) from English to Spanish for studying Mexican Americans in South Texas. Each of the 78 single-word pain descriptors in the original MPQ was translated into Spanish by a panel of nine bilingual health researchers, preserving the original structure of the questionnaire. The pain-intensity content (PIC) of the words in each language was then rated on a 100 mm visual analog scale by 8 bilingual health care providers and 10 bilingual health-care consumers. The correlation between Spanish and English average PIC ratings was strong (r = 0.85 for providers, r = 0.80 for consumers). The translated Spanish version was compared to the original English in a group of 50 bilingual Mexican-American patients with musculoskeletal pain, who completed the MPQ in both languages. There was no difference in Average Pain Rating Index between the Spanish and English versions (29.8 +/- 14.7 vs 29.1 +/- 15.8, p = 0.55), and agreement between the two language versions was almost perfect (ri = 0.85). Test-retest reliability was measured in two groups of hospitalized patients (25 per group), one composed of monolingual Spanish speakers and the other of monolingual English speakers. Each subject completed the MPQ, the McGill Pain Map, two 10-cm visual analog scales measuring pain now and within the past week, the bodily pain items of the MOS-SF36 survey, and the Modified Health Assessment Questionnaire, on two occasions one day apart. Test-retest reliability of the Spanish and English components of the MPQ was not significantly different and was comparable to that of the other pain and health status instruments. We conclude that the Spanish MPQ is cross-culturally equivalent to the original English and has similar concurrent validity and reliability. This questionnaire is suitable for cross-cultural studies of pain comparing Spanish-speaking Mexican Americans with English-speaking members of the same and other ethnic groups.