The development of a battery of measures for assessing physical functioning of chronic pain patients

Effectiveness of a Person-Centered Interdisciplinary Rehabilitation Treatment of Post-COVID-19 Condition: Protocol for a Single-Case Experimental Design Study

BACKGROUND

Patients with post-COVID-19 condition (PCC) experience a wide range of complaints (physical, cognitive, and mental), sometimes with high levels of disability in daily activities. Evidence of effective interdisciplinary rehabilitation treatment is lacking. A person-centered, biopsychosocial, interdisciplinary rehabilitation program, adapted to expert opinions and the patient's needs, was therefore developed.

OBJECTIVE

This study aims to present a study protocol for a clinical trial to evaluate the effect of a new, person-centered, interdisciplinary rehabilitation treatment for PCC. It is aimed at improving participation in society and health-related quality of life in patients with PCC who perceive a high level of disability in daily activities or participation.

METHODS

A total of 20 Dutch adults, aged 18 years or older, with high levels of disability in daily activities and participation in society will be included in this replicated and randomized single-case experimental design study, from October 2023 onward. The replicated and randomized single-case experimental design consists of 3 phases. The baseline phase is the observational period, in which no specific treatment will be given. In the intervention phase, patients will receive the new outpatient treatment 3 times a week for 12 weeks, followed by a 12-week follow-up phase. During the intervention phase, the treatment will be personalized according to the patient's physical, mental, and cognitive symptoms and goals. The treatment team can consist of a rehabilitation physician, physiotherapist, occupational therapist, speech therapist, and psychologist. The primary outcomes of the study are daily diaries, which consist of 8 questions selected from validated questionnaires (Utrecht Scale for Evaluation of Rehabilitation-Participation, EQ-5D-5L, and the Hospital Anxiety and Depression Scale). The other primary outcome measurements are participation in society (Utrecht Scale for Evaluation of Rehabilitation-Participation) and health-related quality of life (EQ-5D-5L). The secondary outcomes are physical tests and validated questionnaires aimed at physical, mental, and cognitive complaints. Effect evaluation based on daily assessments will include visual analysis, calculation of effect sizes (Nonoverlap of All Pairs), randomization tests, and multilevel analysis. In addition, other analyses will be based on ANOVA or a 2-tailed Student t test.

RESULTS

Data collection for this study started in October 2023 and is planned to be completed in July 2024. The results will be published in peer-reviewed journals and presented at international conferences.

CONCLUSIONS

This is the first study investigating the effect of an interdisciplinary rehabilitation treatment with a person-centered, biopsychosocial approach in patients with PCC. Our findings will help to improve the treatment and support of patients with PCC.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00032636; https://drks.de/search/en/trial/DRKS00032636.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63951.

Acute effect of dry needling on trunk kinematics and balance of patients with non-specific low back pain

BACKGROUND

Limited knowledge exists about the effectiveness of dry needling (DN) concerning the torso kinematics in patients with non-specific low back pain (NS-LBP). Acute effects of DN in NS-LBP patients from a functional perspective were investigated.

METHODS

Sixteen NS-LBP patients and 11 healthy individuals (HG) were examined. NS-LBP patients received a single session of DN at the lumbar region. Baseline and immediate post-treatment measurements during flexion-extension and lateral bending of the trunk were conducted for the NS-LBP patients. HG were measured only at baseline to be used as a reference of NS-LBP patients' initial condition. Algometry was applied in NS-LBP patients. Centre of pressure, range of motion of the trunk and its' derivatives were obtained.

FINDINGS

HG performed significantly faster, smoother and with greater mobility in the performed tasks compared to the pre intervention measurements of the NS-LBP patients. For the NS-LBP patients, significant greater angular velocity in frontal plane and significant lower jerk in the sagittal plane were demonstrated post intervention. DN alleviated pain tolerance significantly at the L5 level. Regarding the effectiveness of the DN upon spine kinematics, their derivatives were more sensitive.

INTERPRETATION

It appeared that the pathological type of torso movement was acutely affected by DN. NS-LBP patients showcased smoother movement immediately after the intervention and better control as imprinted in the higher derivative of motion although range of motion did not improve. This quantitative variable may not be subjected to acute effects of DN but rather need additional time and training to be improved.

Moving pain management programmes into the digital age: development and evaluation of an online PMP for people with chronic pain

Introduction

In response to Coronovirus Disease (COVID-19) health care restrictions, the pain management programme delivered group treatment digitally (OPMP). We aimed to: 1) evaluate pain related outcomes of the OPMP, 2) evaluate patient satisfaction and qualitive feedback of the OPMP and 3) compare OPMP outcomes with the pre-pandemic face to face (F2F) PMP outcomes.

Methods

Age, gender, pain duration, occupational status, referral information and patient satisfaction data were collected. Pre- and post-treatment pain related outcomes were compared by calculating mean difference, benchmarking with effect size (Cohen's d) and determining clinically significant change (CSC) for OPMP and F2F PMP.

Results

Two-hundred and thirty-seven patients provided outcome data, with 60 completing the OPMP and 177 completing the F2F PMP. OPMP patients were 10 years younger than the F2F PMP (44.8 vs 53.3), more were female (6.5:1 vs 2.8:1), more were working (45% vs 27%) and fewer were retired (3% vs 17%). The OPMP showed improvements comparable to the F2F PMP. Large effect size was reported across all outcome domains including objective physical outcomes. Eighty-one percent of OPMP patients were 'extremely likely' to recommend the programme but just over 50% of patients felt F2F would provide greater clinical benefits.

Conclusion

The results support that OPMP is effective for carefully selected patients following a multidisciplinary team assessment however more complex cases still require F2F PMP.

Initial Validation of a Sacroiliac Joint-Specific Disability Questionnaire

Low back pain is a multidimensional disorder that can originate from a variety of pain generators, including the sacroiliac (SI) joint. Although the Oswestry Disability Index (ODI) is often used in SI joint treatment studies, the effects of the SI joint on functional disability are likely different from those of other low back pain generators. Thus, we developed the Denver SI Joint Questionnaire (DSIJQ) and performed validation testing in patients (n=24) with SI joint-specific pain at baseline, +2 weeks, and +6 months. Psychometric analyses included test-retest reliability, internal consistency, content validity, convergent criterion validity, divergent criterion validity, and responsiveness. The DSIJQ showed good test-retest reliability (intraclass correlation coefficient=0.87), internal consistency (Cronbach's alpha=0.842), content validity (<30% floor/ceiling effects), convergent criterion validity (r=0.89; P<.001), and divergent criterion validity (r=-0.33; P=.12). The DSIJQ was correlated with performance on two physical function tests: Timed Upand-Go (r=0.53; P=.008) and 5 Minute Walk (r=-0.52; P=.009). The DSIJQ showed better responsiveness than the ODI (standardized response mean and effect size, 1.14 and 1.45 for DSIJQ and 0.75 and 0.81 for ODI). Overall, the DSIJQ performed well on all psychometrics. Importantly, we validated the DSIJQ with patients' ability to complete two tests of physical functioning. Moreover, the DSIJQ was more sensitive to changes in SI joint disability than the ODI. These psychometrics suggest the DSIJQ is appropriate for evaluating SI joint disability and detecting changes in disability after targeted SI joint treatment. [Orthopedics. 2023;46(6):345-351.].

Mindfulness-Based Stress Reduction, Cognitive Behavioral Therapy, and Acupuncture in Chronic Low Back Pain: Protocol for Two Linked Randomized Controlled Trials

BACKGROUND

Nonpharmacologic mind-body therapies have demonstrated efficacy in low back pain. However, the mechanisms underlying these therapies remain to be fully elucidated.

OBJECTIVE

In response to these knowledge gaps, the Stanford Center for Low Back Pain-a collaborative, National Institutes of Health P01-funded, multidisciplinary research center-was established to investigate the common and distinct biobehavioral mechanisms of three mind-body therapies for chronic low back pain: cognitive behavioral therapy (CBT) that is used to treat pain, mindfulness-based stress reduction (MBSR), and electroacupuncture. Here, we describe the design and implementation of the center structure and the associated randomized controlled trials for characterizing the mechanisms of chronic low back pain treatments.

METHODS

The multidisciplinary center is running two randomized controlled trials that share common resources for recruitment, enrollment, study execution, and data acquisition. We expect to recruit over 300 chronic low back pain participants across two projects and across different treatment arms within each project. The first project will examine pain-CBT compared with MBSR and a wait-list control group. The second project will examine real versus sham electroacupuncture. We will use behavioral, psychophysical, physical measure, and neuroimaging techniques to characterize the central pain modulatory and emotion regulatory systems in chronic low back pain at baseline and longitudinally. We will characterize how these interventions impact these systems, characterize the longitudinal treatment effects, and identify predictors of treatment efficacy.

RESULTS

Participant recruitment began on March 17, 2015, and will end in March 2023. Recruitment was halted in March 2020 due to COVID-19 and resumed in December 2021.

CONCLUSIONS

This center uses a comprehensive approach to study chronic low back pain. Findings are expected to significantly advance our understanding in (1) the baseline and longitudinal mechanisms of chronic low back pain, (2) the common and distinctive mechanisms of three mind-body therapies, and (3) predictors of treatment response, thereby informing future delivery of nonpharmacologic chronic low back pain treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02503475; https://clinicaltrials.gov/ct2/show/NCT02503475.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37823.

In the Shoulder or in the Brain? Behavioral, Psychosocial and Cognitive Characteristics of Unilateral Chronic Shoulder Pain with Symptoms of Central Sensitization

The recognition of central sensitization (CS) is crucial, as it determines the results of rehabilitation. The aim of this study was to examine associations between CS and catastrophizing, functionality, disability, illness perceptions, kinesiophobia, anxiety, and depression in people with chronic shoulder pain (SP). In this cross-sectional study, 64 patients with unilateral chronic SP completed a few questionnaires including the Central Sensitization Inventory, the Oxford Shoulder Score, the Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, the Pain Catastrophizing Scale, the Brief Illness Perception Questionnaire and the “arm endurance” test. On the basis of three constructed linear regression models, it was found that pain catastrophizing and depression (model 1: p < 0.001, R = 0.57, R2 = 0.33), functionality (model 2: p < 0.001, R = 0.50, R2 = 0.25), and helplessness (model 3: p < 0.001, R = 0.53, R2 = 0.28) were significant predictors for CS symptoms in chronic SP. Two additional logistic regression models also showed that depression (model 4: p < 0.001, Nagelkerke R2 = 0.43, overall correct prediction 87.5%) and functionality (model 5: p < 0.001, Nagelkerke R2 = 0.26, overall correct prediction 84.4%) can significantly predict the classification of chronic SP as centrally sensitized. Patients who were classified as centrally sensitized (n = 10) were found to have significantly worse functionality, psychological factors (anxiety, depression, kinesiophobia, catastrophizing), and pain intensity (p < 0.05). Catastrophizing, depression, and functionality are predictive factors of CS symptoms in patients with chronic shoulder pain. Health care providers should adopt a precision medicine approach during assessment and a holistic rehabilitation of patients with unilateral chronic SP.

Sciatic nerve injury rebalances the hypothalamic-pituitary-adrenal axis in rats with persistent changes to their social behaviours

Increased glucocorticoids characterise acute pain responses, but not the chronic pain state, suggesting specific modifications to the hypothalamic-pituitary-adrenal (HPA)-axis preventing the persistent nature of chronic pain from elevating basal glucocorticoid levels. Individuals with chronic pain mount normal HPA-axis responses to acute stressors, indicating a rebalancing of the circuits underpinning these responses. Preclinical models of chronic neuropathic pain generally recapitulate these clinical observations, but few studies have considered that the underlying neuroendocrine circuitry may be altered. Additionally, individual differences in the behavioural outcomes of these pain models, which are strikingly similar to the range of behavioural subpopulations that manifest in response to stress, threat and motivational cues, may also be reflected in divergent patterns of HPA-axis activity, which characterises these other behavioural subpopulations. We investigated the effects of sciatic nerve chronic constriction injury (CCI) on adrenocortical and hypothalamic markers of HPA-axis activity in the subpopulation of rats showing persistent changes in social interactions after CCI (Persistent Effect) and compared them with rats that do not show these changes (No Effect). Basal plasma corticosterone did not change after CCI and did not differ between groups. However, adrenocortical sensitivity to adrenocorticotropic hormone (ACTH) diverged between these groups. No Effect rats showed large increases in basal plasma ACTH with no change in adrenocortical melanocortin 2 receptor (MC₂ R) expression, whereas Persistent Effect rats showed modest decreases in plasma ACTH and large increases in MC₂ R expression. In the paraventricular nucleus of the hypothalamus of Persistent Effect rats, single labelling revealed significantly increased numbers of corticotropin releasing factor (CRF) +ve and glucocorticoid receptor (GR) +ve neurons. Double-labelling revealed fewer GR +ve CRF +ve neurons, suggesting a decreased hypothalamic sensitivity of CRF neurons to circulating corticosterone in Persistent Effect rats. We suggest that in addition to rebalancing the HPA-axis, the increased CRF expression in Persistent Effect rats contributes to changes in complex behaviours, and in particular social interactions.

Young Adult Cannabis Users' Perceptions of Cannabis Risks and Benefits by Chronic Pain Status

Purpose: Young adults experiencing chronic pain may self-medicate with cannabis. We examined perceived risks and benefits of cannabis use among young adult users by chronic pain status, and identified relationships among perceived risks and benefits, physical and mental health, and cannabis-related problems. Methods: Young adults reporting at least weekly cannabis use (N = 176, 50.9% with chronic pain) reported perceptions of lifetime risks and benefits associated with cannabis use, physical and mental health, and cannabis-related problems. Results: Young adults without chronic pain reported better physical and mental health than those with chronic pain. Cannabis use, problems, and risk and benefit perceptions did not differ by pain status. Risk and benefit perceptions were unrelated to physical health, perceiving fewer risks and more benefits was associated with better mental health, and perceiving more risk was associated with cannabis problems. Chronic pain status moderated the relationship between perceived benefits and outcomes, such that perceiving more benefits was associated with better physical health for those without chronic pain. Further, greater perceived benefits were associated with more cannabis-related problems for those without chronic pain but fewer problems for those with chronic pain. Conclusion: This study offers insight into the perceptions of risks and benefits among young adult cannabis users and associations with physical and mental health and cannabis-related problems. The effects of perceived benefits on physical health and cannabis-related problems differs for young adults with and without pain, suggesting assessment and consideration of pain status may be valuable in intervention contexts.

Evidence that increased cholecystokinin (CCK) in the periaqueductal gray (PAG) facilitates changes in Resident-Intruder social interactions triggered by peripheral nerve injury

Individual differences in the effects of a chronic neuropathic injury on social behaviours characterize both the human experience and pre-clinical animal models. The impacts of these changes to the well-being of the individual are often underappreciated. Earlier work from our laboratory using GeneChip® microarrays identified increased cholecystokinin (CCK) gene expression in the periaqueductal gray (PAG) of rats that showed persistent changes in social interactions during a Resident-Intruder encounter following sciatic nerve chronic constriction injury (CCI). In this study, we confirmed these gene regulation patterns using RT-PCR and identified the anatomical location of the CCK-mRNA as well as the translated CCK peptides in the midbrains of rats with a CCI. We found that rats with persistent CCI-induced changes in social behaviours had increased CCK-mRNA in neurons of the ventrolateral PAG and dorsal raphe nuclei, as well as increased CCK-8 peptide expression in terminal boutons located in the lateral and ventrolateral PAG. The functional significance of these changes was explored by microinjecting small volumes of CCK-8 into the PAG of uninjured rats and observing their Resident-Intruder social interactions. Disturbances to social interactions identical to those observed in CCI rats were evoked when injection sites were located in the rostral lateral and ventrolateral PAG. We suggest that CCI-induced changes in CCK expression in these PAG regions contributes to the disruptions to social behaviours experienced by a subset of individuals with neuropathic injury.

The effects of dry needling on pain relief and functional balance in patients with sub-chronic low back pain

BACKGROUND

Pain relief is important both for the movement of patients suffering from low back pain and the quality of life. Dry needling is effective on myofascial trigger points but its effect on the area of pain and the functional balance is not fully known.

OBJECTIVE

To examine the immediate effect of dry needling on pain and functional balance of patients suffering from low back pain.

METHODS

Twenty five patients with sub-chronic low back pain were randomly divided into two groups: the intervention or control group. Needles were used for the participants of the intervention group, bilaterally at the spinus level, one and a half finger breath from the midline in levels L2-L5 of the lumbar spine. A third line of needles was inserted in the interspinosus spaces, except L5-S1 level. Bipedal stance, lateral loading and mediolateral body sway were assessed using a pair of force plates. Pain tolerance was assessed using an algometer.

RESULTS

The pain tolerance significantly increased in the intervention group from (M = 4.87, SE 0.663) to (M = 6.52, SE 0.547) (F(1,23) = 7.8, p< 0.05) after intervention. During mediolateral body sway the force signal in the dominant frequency significantly increased in the intervention group from (M = 43.2, SE 4.6) to (M = 54,9, SE 3.6) (F(1,23) = 4.63, p< 0.05) after intervention, exhibiting more controlled rhythmic behavior.

CONCLUSIONS

Dry needling in painful areas and penetrating all the muscle groups seems to improve pain and functional balance, yet its effect on specific muscles needs to be studied further.

High-Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Nonsurgical Refractory Back Pain: Design of a Pragmatic, Multicenter, Randomized Controlled Trial

BACKGROUND

Spinal cord stimulation (SCS) has been shown to provide pain relief for chronic back and leg pain due to failed back surgery syndrome. But many patients with chronic back pain have not had major back surgery or are not good candidates for surgery, and conventional medical management (CMM) provides limited relief. We have termed this condition nonsurgical refractory back pain (NSRBP). Level 1 evidence does not yet exist showing the therapeutic benefit of SCS for NSRBP.

OBJECTIVE

To compare 10-kHz SCS plus CMM (10-kHz SCS + CMM) to CMM alone for treatment of NSRBP in terms of clinical and cost effectiveness.

STUDY DESIGN

Multicenter, randomized controlled trial (RCT), with subjects randomized 1:1 to either 10-kHz SCS + CMM or CMM alone. Optional crossover occurs at 6 months if treatment does not achieve ≥50% pain relief.

METHODS

Patients with NSRBP as defined above may be enrolled if they are ineligible for surgery based on surgical consultation. Subjects randomized to 10-kHz SCS + CMM will receive a permanent implant if sufficient pain relief is achieved in a temporary trial. Both groups will receive CMM per standard of care and will undergo assessments at baseline and at follow-ups to 12 months. Self-report outcomes include pain, disability, sleep, mental health, satisfaction, healthcare utilization, and quality of life.

RESULTS

Enrollment was initiated on September 10, 2018. Prespecified independent interim analysis at 40% of the enrollment target indicated the sample size was sufficient to show superiority of treatment at the primary endpoint; therefore, enrollment was stopped at 211.

CONCLUSIONS

This large multicenter RCT will provide valuable evidence to guide clinical decisions in NSRBP.

A tool to improve functional outcome assessment of a multimodal program for patients with chronic low back pain: A study on walk tests (at comfortable and fast speed)

BACKGROUND

Tools for functional assessment of chronic low back pain (LBP) are lacking.

OBJECTIVE

To determine the correlations and the responsiveness of the 400 m comfortable walk test (400 mCWT) and the 200 m fast-walk test (200 mFWT) in the functional assessment of a multimodal program.

METHODS

One hundred and twenty-seven participants (68 females) with LBP and with or without radicular pain completed a Quebec Back Pain Disability Scale, a Sorensen test, a Shirado test, a 400 mCWT and a 200 mFWT, at baseline and at the end of the program.

RESULTS

No significant side effect was reported during walk tests. Walking speed was significantly increased after the program (0.18 ± 0.15 m.s-1 for the 400 mCWT and 0.17 ± 0.17 m.s-1 for the 200 mFWT). Clinical parameters were also significantly improved (82.02 ± 83.1 seconds for the Shirado, 92.1 ± 100.1 seconds for the Sorensen, -14.0 ± 12.9 for the Quebec scale). A significant relationship was found between the increase in walking speed for the two walk tests and the improvement of the Quebec scale. The gait speed improvement was close to the minimal clinically important change (95% confidence interval: 0.14-0.22) determined from the Quebec scale threshold (minimum detectable change).

CONCLUSIONS

Both 400 mCWT and 200 mFWT are correlated with functional parameters and are responsive for the functional assessment of LBP.

Balance ability and posture in postmenopausal women with chronic pelvic pain

OBJECTIVE

The aim of the present study was to analyze balance ability and posture in postmenopausal women with chronic pelvic pain (CPP).

METHODS

This study includes a sample of 48 women with CPP recruited from the Gynecology Service of Virgen de las Nieves and San Cecilio Hospitals in Granada (Spain) and 48 healthy control women matched with respect to age and anthropometric characteristics. Outcome variables collected included: balance ability (Mini-Balance Evaluation Systems Test and Timed Up an Go Test) and posture (photogrammetry and Spinal Mouse).

RESULTS

Significant differences were found in all Mini Best Test subscales: total (P < 0.001), anticipatory (P = 0.002), reactive postural control (P < 0.001), sensory orientation (P < 0.001), and dynamic gait (P < 0.001), and all Timed Up and Go test subscales: alone (P < 0.001), with manual (P = 0.002) and cognitive task (P = 0.030). Significant differences were also found on spinal cervical angles with a forward head posture in women with CPP; global spine alignment exhibited more deviation in the women with CPP (P < 0.001); and a higher percentage of women with CPP (58%) presented with increased thoracic kyphosis and lumbar lordosis. Cohen's d was used to calculate the effect size. Some subscales of balance and posture tests showed a large effect size (d ≥0.8), indicating a more consistent result.

CONCLUSIONS

Women with CPP presented poor balance including anticipatory, reactive postural control, sensory orientation, dynamic gait, and dual task-related conditions. Posture showed higher values on the dorsal angle and lower sacral inclination, less spine alignment, and a more prevalent posture with increased kyphosis and lumbar lordosis.

Level of Evidence for Reliability, Validity, and Responsiveness of Physical Capacity Tasks Designed to Assess Functioning in Patients With Low Back Pain: A Systematic Review Using the COSMIN Standards

BACKGROUND

Physical capacity tasks (ie, observer-administered outcome measures that comprise a standardized activity) are useful for assessing functioning in patients with low back pain.

PURPOSE

The purpose of this study was to systematically review the level of evidence for the reliability, validity, and responsiveness of physical capacity tasks.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, Scopus, the Cochrane Library, and relevant reference lists were used as data sources.

STUDY SELECTION

Two authors independently selected articles addressing the reliability, validity, and responsiveness of physical capacity tasks, and a third author resolved discrepancies.

DATA EXTRACTION AND QUALITY ASSESSMENT

One author performed data extraction, and a second author independently checked the data extraction for accuracy. Two authors independently assessed the methodological quality with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) 4-point checklist, and a third author resolved discrepancies.

DATA SYNTHESIS AND ANALYSIS

Data synthesis was performed by all authors to determine the level of evidence per measurement property per physical capacity task. The 5-repetition sit-to-stand, 5-minute walk, 50-ft (∼15.3-m) walk, Progressive Isoinertial Lifting Evaluation, and Timed "Up & Go" tasks displayed moderate to strong evidence for positive ratings of both reliability and construct validity. The 1-minute stair-climbing, 5-repetition sit-to-stand, shuttle walking, and Timed "Up & Go" tasks showed limited evidence for positive ratings of responsiveness.

LIMITATIONS

The COSMIN 4-point checklist was originally developed for patient-reported outcome measures and not physical capacity tasks.

CONCLUSIONS

The 5-repetition sit-to-stand, 50-ft walk, 5-minute walk, Progressive Isoinertial Lifting Evaluation, Timed "Up & Go," and 1-minute stair-climbing tasks are promising tests for the measurement of functioning in patients with chronic low back pain. However, more research on the measurement error and responsiveness of these tasks is needed to be able to fully recommend them as outcome measures in research and clinical practice.

One-minute stair climbing, 50-foot walk, and timed up-and-go were responsive measures for patients with chronic low back pain undergoing lumbar fusion surgery

Background

Physical capacity tasks are useful tools to assess functioning in patients with low back pain (LBP), but evidence is scarce regarding the responsiveness (ability to detect change over time) and minimal important change (MIC). The aim was to investigate the responsiveness and MIC of 5-min walk, 1-min stair climbing, 50-ft walk, and timed up-and-go in patients with chronic LBP undergoing lumbar fusion surgery.

Methods

In this clinimetric study, 118 patients scheduled for lumbar fusion surgery for motion-elicited chronic LBP with degenerative changes were included. All patients performed the physical capacity tasks 5-min walk, 1-min stair climbing, 50-ft walk, and timed up-and-go 8–12 weeks before and six months after surgery. Responsiveness was evaluated by testing five a priori responsiveness hypotheses. The hypotheses concerned the area under the receiver operating characteristics (ROC) curve and correlations (Spearman’s rho) between the change scores of the physical capacity tasks, the Oswestry Disability Index 2.0 (ODI), and back pain intensity measured with visual analog scale (VAS). At least 80% of the hypotheses would have to be confirmed for adequate responsiveness. Absolute and relative MICs for improvement were determined by the optimal cut-off point of the ROC curve based on the classification of improved and unchanged patients according to construct-specific global perceived effect (GPE) scales.

Results

One-minute stair climbing, 50-ft walk and timed up-and-go displayed adequate responsiveness (≥ 80% of hypotheses confirmed), while 5-min walk did not (40% of hypotheses confirmed). The absolute MICs for improvement were 45.5 m for 5-min walk, 20.0 steps for 1-min stair climbing, − 0.6 s for 50-ft walk, and − 1.3 s for timed up-and-go.

Conclusions

The results of responsiveness for 1-min stair climbing, 50-ft walk, and timed up-and-go implies that these have the ability to detect changes in physical capacity over time in patients with chronic LBP who have undergone lumbar fusion surgery.

Comparison of STarT Back Screening Tool and Simmonds Physical Performance Based Test Battery in Prediction of Disability Risks Among Patients with Chronic Low-Back Pain

Objectives This study identified disability sub-groups of patients with chronic low back pain (LBP) using the Subgroup for Targeted Treatment (or STarT) Back Screening Tool (SBST) and Simmonds Physical Performance Tests Battery (SPPTB). In addition, the study investigated the divergent validity of SBST, and compared the predictive validity of SBST and SPPTB among the patients with the aim to enhance quick and accurate prediction of disability risks among patients with chronic LBP. Methods This exploratory cross-sectional study involved 70 (52.0% female and 47.1% male) consenting patients with chronic non-specific LBP attending out-patient physiotherapy and Orthopedic Clinics at the Obafemi Awolowo University Teaching Hospitals, Ile-Ife and Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria. Disability risk subgrouping and prediction were carried out using the SBST and SPPTB (comprising six functional tasks of repeated trunk flexion, sit-to-stand, 360-degree rollover, Sorenson fatigue test, unloaded reach test, and 50 foot walk test). Pain intensity was assessed using the Quadruple Visual Analogue Scale. Data on age, sex, height, weight and BMI were also collected. Descriptive and inferential statistics were used to analyze data at p<0.05 Alpha level. Results The mean age, weight, height and body mass index of the participants were 51.4 ±8.78 years, 1.61 ±0.76 m and 26.6 ±3.18 kg/m2 respectively. The mean pain intensity and duration were 5.37 ±1.37 and 21.2 ±6.68 respectively. The divergent validity of SBST with percentage overall pain intensity was r = 0.732; p = 0.001. Under SBST sub-grouping the majority of participants were rated as having medium disability risk (76%), whilst SPPTB sub-grouped the majority as having high disability risk (71.4%). There was a significant difference in disability risk subgrouping between SBST and SPPTB (χ²=12.334; p=0.015). SBST had no floor and ceiling effects, as less than 15% of the participants reached the lowest (2.9%) or highest (1.4%) possible score. Conversely, SPPBT showed both floor and ceiling effects, as it was unable to detect ‘1’ and ‘9’, the lowest and highest obtainable scores. The ‘Area Under Curve’ for sensitivity (0.83) and specificity (0.23) of the SBST to predict ‘high-disability risk’ was 0.51. The estimated prevalence for ‘high-disability risk’ prediction of SBST was 0.76. The estimate for true positive, false positive, true negative and false negative for prediction of ‘high-disability risk’ for SBST were 0.77, 0.23, 0.31, and 0.69 respectively. Conclusion The Start Back Screening Tool is able to identify the proportion of patients with low back pain with moderate disability risks, while the Simmonds Physical Performance Tests Battery is better able to identify high disability risks. Thus, SBST as a self-report measure may not adequately substitute physical performance assessment based disability risks prediction. However, SBST has good divergent predictive validity with pain intensity. In contrast to SPBBT, SBST exhibited no floor or ceiling effects in our tests, and demonstrated high sensitivity but low specificity in predicting ‘high-disability risk’.

Cross-Cultural Adaptation, Validity, and Reliability Study of the Turkish Version of Back Performance Scale

STUDY DESIGN

Validation of a performance scale.

OBJECTIVE

The purpose of this study is to investigate adaptation, validity, and reliability of the Turkish version of the Back Performance Scale (BPS).

SUMMARY OF BACKGROUND DATA

Low back pain affects people of all ages and causes pain, disability, and psychosocial problems. BPS is a condition-specific performance measure of activity limitation in patients with low back pain. The purpose of this study is to investigate the cross-cultural adaptation, validity, and reliability of the Turkish version of the BPS.

METHODS

The study included 180 patients with low back pain. For the reliability assessment of the scale, test-retest, and internal consistency analyses were performed. The results of the test-retest analysis were analyzed by Intraclass Correlation Coefficient (ICC) method. For the internal consistency, Cronbach Alpha value was calculated and to construct validity, total points of the BPS were compared with the total points of Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) using Pearson correlation coefficient analysis.

RESULTS

BPS was found to have high internal consistency (Cronbach alpha value 0.827). Test-retest results were found highly correlated (range from 0.723 to 0.899). Factor analysis indicated that the scale had one factor. BPS is well correlated with RMDQ and ODI (Pearson correlation coefficient with RMDQ 0.576 and with ODI 0.603).

CONCLUSION

The Turkish version of BPS is valid and reliable.

LEVEL OF EVIDENCE

3.

Integrating culturally informed approaches into physiotherapy assessment and treatment of chronic pain: a pilot randomised controlled trial

OBJECTIVE

To evaluate patient engagement with, and the feasibility of, a novel, culturally adapted physiotherapy pain management approach.

DESIGN

A participant-blinded and assessor-blinded pilot randomised controlled trial.

SETTING

Outpatient physiotherapy departments at two public hospitals and one district pain clinic.

PARTICIPANTS

Adults (n=48) with chronic musculoskeletal pain (daily pain >3 months), who self-identified as Mandaean, Assyrian or Vietnamese, were randomised to one of two physiotherapy treatment conditions.

INTERVENTIONS

24 participants underwent combined group and individualised treatment described as 'culturally adapted physiotherapy', while 24 underwent evidence-informed 'usual physiotherapy care'. Both treatment arms consisted of up to 10 sessions over a 3-month period.

OUTCOME MEASURES

Patient engagement was measured via participant attendance, adherence and satisfaction data. Secondary outcomes included clinical measures of pain severity, interference and suffering, physical function and negative emotional state.

RESULTS

96% of participants undergoing culturally adapted physiotherapy completed treatment, compared with 58% of the usual physiotherapy group. For the culturally adapted group attendance (87%±18%) and adherence (68%±32%) were higher relative to usual care (68%±32% and 55%±43%). Satisfaction was similar for the culturally adapted (82.7%±13.4%) and usual care (79.3±17.3) groups. For secondary outcomes, a significant between-group effect for pain-related suffering in favour of the culturally adapted group was observed with a medium effect size (partial η2 0.086, mean 3.56, 95% CI 0.11 to 7), while results for pain severity, interference, physical function and negative emotional state were similar.

CONCLUSIONS

Aligning treatment with the beliefs and values of culturally and linguistically diverse communities enhances patient engagement with physiotherapy. These results support the feasibility of a larger, multisite trial to determine if improved engagement with culturally adapted physiotherapy translates to improved clinical outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12616000857404; Pre-results.

Reducing sedentary behaviour to decrease chronic low back pain: the stand back randomised trial

OBJECTIVE

The Stand Back study evaluated the feasibility and effects of a multicomponent intervention targeting reduced prolonged sitting and pain self-management in desk workers with chronic low back pain (LBP).

METHODS

This randomised controlled trial recruited 27 individuals with chronic LBP, Oswestry Disability Index (ODI) >10% and desk jobs (sitting ≥20 hours/week). Participants were randomised within strata of ODI (>10%-<20%, ≥20%) to receive bimonthly behavioural counselling (in-person and telephone), a sit-stand desk attachment, a wrist-worn activity-prompting device and cognitive behavioural therapy for LBP self-management or control. Self-reported work sitting time, visual analogue scales (VAS) for LBP and the ODI were assessed by monthly, online questionnaires and compared across intervention groups using linear mixed models.

RESULTS

Baseline mean (SD) age was 52 (11) years, 78% were women, and ODI was 24.1 (10.5)%. Across the 6-month follow-up in models adjusted for baseline value, work sitting time was 1.5 hour/day (P<0.001) lower comparing intervention to controls. Also across follow-up, ODI was on average 8 points lower in intervention versus control (P=0.001). At 6 months, the relative decrease in ODI from baseline was 50% in intervention and 14% in control (P=0.042). LBP from VAS was not significantly reduced in intervention versus control, though small-to-moderate effect sizes favouring the intervention were observed (Cohen's d ranged from 0.22 to 0.42).

CONCLUSION

An intervention coupling behavioural counselling targeting reduced sedentary behaviour and pain self-management is a translatable treatment strategy that shows promise for treating chronic LBP in desk-bound employees.

TRIAL REGISTRATION NUMBER

NCT0224687; Pre-results.

Randomized Controlled Trial of Online Acceptance and Commitment Therapy for Fibromyalgia

In this study, 67 participants (95% female) with fibromyalgia (FM) were randomly assigned to an online acceptance and commitment therapy (online ACT) and treatment as usual (TAU; ACT + TAU) protocol or a TAU control condition. Online ACT + TAU participants were asked to complete 7 modules over an 8-week period. Assessments were completed at pre-treatment, post-treatment, and 3-month follow-up periods and included measures of FM impact (primary outcome), depression, pain, sleep, 6-minute walk, sit to stand, pain acceptance (primary process variable), mindfulness, cognitive fusion, valued living, kinesiophobia, and pain catastrophizing. The results indicated that online ACT + TAU participants significantly improved in FM impact, relative to TAU (P <.001), with large between condition effect sizes at post-treatment (1.26) and follow-up (1.59). Increases in pain acceptance significantly mediated these improvements (P = .005). Significant improvements in favor of online ACT + TAU were also found on measures of depression (P = .02), pain (P = .01), and kinesiophobia (P = .001). Although preliminary, this study highlights the potential for online ACT to be an efficacious, accessible, and cost-effective treatment for people with FM and other chronic pain conditions.

PERSPECTIVE

Online ACT reduced FM impact relative to a TAU control condition in this randomized controlled trial. Reductions in FM impact were mediated by improvements in pain acceptance. Online ACT appears to be a promising intervention for FM.

Effects of functional resistance training on fitness and quality of life in females with chronic nonspecific low-back pain

BACKGROUND

Exercise is important as adjuvant in the chronic low back pain (CLBP) treatment. Functional training could involve benefits for low back pain (LBP) patients.

OBJECTIVE

To evaluate the effects of a 12-week period of functional resistance training on health-related quality of life (HRQOL), disability, body pain, and physical fitness in CLBP females.

METHODS

Nineteen females CLBP were recruited according to Paris Task Force on Back Pain criteria. Participants were randomly assigned to an exercise group (EG); and a control group (CG). Subjects were tested at baseline and at week 12 after 24 sessions, 2 days per week. Body pain was assessed using visual analog scale (VAS), disability with Oswestry Disability Index (ODI) and HRQOL with Short Form 36 questionnaire. Physical fitness was measured using: flamingo test, back endurance test, side bridge test, abdominal curl-up tests, and 60-s squat test.

RESULTS

EG showed significant improvements in physical function (10%; p< 0.05), body pain (42%; p< 0.05), vitality (31%; p< 0.05), physical component scale (15%; p< 0.05), VAS (62.5%; p< 0.01), ODI (61.3%; p< 0.05), balance (58%; p< 0.05), curl-up (83%; p< 0.01), squat (22%; p< 0.01), static back (67%; p< 0.01), and side bridge (56%; p< 0.01).

CONCLUSION

Periodized functional resistance training decreased pain and disability and improved HRQOL, balance and physical fitness in females with CLBP, and can thus be used safely in this population.

Association Between Symptoms of Central Sensitization and Cognitive Behavioral Factors in People With Chronic Nonspecific Low Back Pain: A Cross-sectional Study

OBJECTIVE

The objective of this cross-sectional study was to analyze the relationship between symptoms of central sensitization (CS) and important cognitive behavioral and psychosocial factors in a sample of patients with chronic nonspecific low back pain.

METHODS

Participants with chronic nonspecific low back pain for at least 3 months were included in the study. They completed several questionnaires and a functional test. Pearson's correlation was used to analyze associations between symptoms of CS and pain behavior, functioning, pain, pain catastrophizing, kinesiophobia, and illness perceptions. Additionally, a between-group analysis was performed to compare patients with and without clinically relevant symptoms of CS.

RESULTS

Data from 38 participants were analyzed. Significant associations were found between symptoms of CS and all other outcomes, especially current pain (r = 0.510, P = .001), mean pain during the past 7 days (r = 0.505, P = .001), and pain catastrophizing (r = 0.518, P = .001). Patients with clinically relevant symptoms of CS scored significantly worse on all outcomes compared with persons without relevant symptoms of CS, except on functioning (P = .128).

CONCLUSIONS

Symptoms of CS were significantly associated with psychosocial and cognitive behavioral factors. Patients exhibiting a clinically relevant degree of symptoms of CS scored significantly worse on most outcomes, compared with the subgroup of the sample with fewer symptoms of CS.

Different types of exercise in Multiple Sclerosis: Aerobic exercise or Pilates, a single-blind clinical study

BACKROUND

The aim of our study is to examine effects of aerobic and Pilates exercises on disability, cognition, physical performance, balance, depression and fatigue in relapsing-remitting Multiple Sclerosis (MS) patients as compared to healthy controls.

METHODS

The subjects were divided as aerobic exercise (n = 26), Pilates (n = 9), and the healthy control group (n = 21). We used MSFC, physical performance, Berg balance scale, Beck depression scale, fatigue impact scale. All evaluations were performed before and after exercise training.

RESULTS

There are statistically meaningful differences between Nine hole testing, PASAT 3, physical performance and fatique impact scale before and after aerobic exercise. Also we found significant difference for physical performance in the Pilates group. There are no significant differences in measures of fatique impact scale and depression between aerobic exercise group and the healthy controls after exercise. We found significant differences between Pilates and control group's after measurements except depression. There were significant differences between the Pilates and aerobic group for cognitive tests in favor of the Pilates group.

CONCLUSION

Aerobic exercise and clinical Pilates exercises revealed moderate changes in levels of cognitive, physical performance, balance, depression, fatigue in MS patients.

Magnetic resonance imaging (MRI)-defined cartilage degeneration and joint pain are associated with poor physical function in knee osteoarthritis - the Oulu Knee Osteoarthritis study

OBJECTIVE

The main aim was to investigate the associations between Magnetic Resonance Imaging (MRI)-defined structural pathologies of the knee and physical function.

DESIGN

A cohort study with frequency matching on age and sex with eighty symptomatic subjects with knee pain and suspicion or diagnosis of knee osteoarthritis (OA) and 57 asymptomatic subjects was conducted. The subjects underwent knee MRI, and the severity of structural changes was graded by MRI Osteoarthritis Knee Score (MOAKS) in separate knee locations. WOMAC function subscores were recorded and physical function tests (20-m and 5-min walk, stair ascending and descending, timed up & go and repeated sit-to-stand tests) performed. The association between MRI-defined structural pathologies and physical function tests and WOMAC function subscores were evaluated by linear regression analysis with adjustment for demographic factors, other MRI-features and pain with using effect size (ES) as a measure of the magnitude of an association.

RESULTS

Cartilage degeneration showed significant association with poor physical performance in TUG-, stair ascending and descending-, 20-m- and 5-min walk-tests (ESs in the subjects with cartilage degeneration anywhere between 0.134 [95%CI 0.037-0.238] and 0.224 [0.013-0.335]) and with increased WOMAC function subscore (ES in the subjects with cartilage degeneration anywhere 0.088 [0.012-0.103]). Also, lateral meniscus maceration and extrusion were associated with poor performance in stair ascending test (ESs 0.067 [0.008-0.163] and 0.077 [0.012-0.177]).

CONCLUSIONS

After adjustments cartilage degeneration was associated with both decreased self-reported physical function and poor performance in the physical function tests. Furthermore, subjects with lateral meniscus maceration and extrusions showed significantly worse performance in stair ascending tests.

Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change

Long-term use of opioid medication is associated with a host of negative effects on health and quality of life. Guidelines state that people with chronic pain taking high doses of opioids without benefit should be supported to discontinue them. Little research has investigated psychological processes associated with analgesic use and tapering. This study investigated (1) analgesic use pre- and post-participation in an interdisciplinary pain management programme and its relationship to functioning and (2) psychological processes associated with analgesic use. Opioid use was associated with poorer functioning at baseline. Participating in an interdisciplinary pain management programme was associated with reductions in opioid dose and number of classes of analgesics used. Reductions in analgesic use were associated with improvements in functioning. Psychological inflexibility was associated with using higher doses of opioid medication and with using a greater number of classes of analgesics. Psychological flexibility appears relevant in explaining analgesic use. Future research could focus on targeting this process to improve tapering outcomes.

Predictors for future activity limitation in women with chronic low back pain consulting primary care: a 2-year prospective longitudinal cohort study

OBJECTIVES

To assess if body function, activity, participation, health-related quality of life and lifestyle behavioural factors can predict activity limitation in women with chronic low back pain (CLBP) in primary healthcare (PHC) 2 years later.

DESIGN

A 2-year prospective longitudinal cohort study within PHC.

SETTINGS

PHC in southwestern Sweden.

PARTICIPANTS

The cohort comprised 130 women with CLBP attending PHC at baseline 2004-2005 and were reassessed after 2 years.

MEASURES

The dependent outcome variable was self-reported activity limitation (Roland Morris disability questionnaire (RMDQ)) at 2-year follow-up. Independent predictors at baseline were age, body mass index, smoking, alcohol consumption, sleep quantity and quality, leisure time physical activity, a questionnaire of clinical manifestation of stress (Stress and Crises Inventory (SCI-93)), pain localisation, pain intensity, fatigue, anxiety, depression, RMDQ, work status, private social support, health-related quality of life and measures of physical performance specified as 6 min walk test (6MWT) and hand grip strength. Relation between baseline predictors and variation in later self-reported activity limitation (RMDQ) was analysed using multivariate linear regression.

RESULTS

Ninety-five per cent (n=123/130) were followed up after 2 years. The participants were middle-aged (mean 45 (SD 10) years), mostly educated >9 years (88%; 108/123), mainly living with another adult (76%; 93/122) and born in Sweden (90%; 111/123). Seventy-nine per cent (97/123) were categorised as having work ability at baseline. The final prognostic model including 6MWT, SCI-93 and RMDQ at baseline explained 54% of the variance in self-reported activity limitation (RMDQ) at the 2-year follow-up.

CONCLUSIONS

Lower physical performance, more severe clinical stress symptoms and more severe activity limitation predicted activity limitation after 2 years in women with CLBP within PHC. The results can give guidance for interventional trials aiming to improve physical capacity and decrease stress. The impact of the interaction between prognostic factors and interventions on activity limitation needs further investigation.

Integrating culturally informed approaches into the physiotherapy assessment and treatment of chronic pain: protocol for a pilot randomised controlled trial

INTRODUCTION

There is strong evidence that biopsychosocial approaches are efficacious in the management of chronic pain. However, implementation of these approaches in clinical practice is known not to account for the beliefs and values of culturally and linguistically diverse (CALD) patients. This limitation in translation of research contributes to the disparities in outcomes for CALD patients with chronic pain adding to the socioeconomic burden of this prevalent condition. Cultural adaptation of chronic pain assessment and management is urgently required. Thus, the aim of this pilot randomised controlled trial (RCT) is to determine the feasibility, participant acceptance with and clinical effectiveness of a culturally adapted physiotherapy assessment and treatment approach when contrasted with 'usual evidence based physiotherapy care' for three CALD communities.

METHODS AND ANALYSIS

Using a participant-blinded and assessor-blinded randomised controlled pilot design, patients with chronic pain who self-identify as Assyrian, Mandaean or Vietnamese will be randomised to either 'culturally adapted physiotherapy assessment and treatment' or 'evidence informed usual physiotherapy care'. We will recruit 16 participants from each ethnocultural community that will give a total of 24 participants in each treatment arm. Both groups will receive physiotherapy treatment for up to 10 sessions over 3 months. Outcomes including feasibility data, acceptance with the culturally adapted intervention, functional and pain-related measures will be collected at baseline and 3 months by a blinded assessor. Analysis will be descriptive for feasibility outcomes, while measures for clinical effectiveness will be explored using independent samples t-tests and repeated measures analysis of variance. This analysis will inform sample size estimates while also allowing for identification of revisions in the protocol or intervention prior to a larger scale RCT.

ETHICS AND DISSEMINATION

This trial has full ethical approval (HREC/16/LPOOL/194). The results from this pilot RCT will be presented at scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12616000857404.

Correlation between gait analysis and clinical questionnaires in patients with spontaneous osteonecrosis of the knee

BACKGROUND

Spontaneous osteonecrosis of the knee is usually verified by magnetic resonance imaging accompanied by clinical questionnaires to assess the level of pain and functional limitation. There is a lack however, in an objective functional test that will reflect the functional severity of spontaneous osteonecrosis of the knee. The purpose of the current study was to examine the correlation between spatiotemporal gait parameters and clinical questionnaires in patients with spontaneous osteonecrosis of the knee.

METHODS

28 patients (16 females and 12 males) were included in the analysis. Patients had unilateral spontaneous osteonecrosis of the knee of the medial femoral condyle confirmed by magnetic resonance imaging. All patients performed a computerized spatiotemporal gait analysis and completed the Western Ontario and McMaster University Osteoarthritis Index and the Short-Form 36. Relationships between selected spatiotemporal gait measures and self-assessment questionnaires were assessed by Spearman non-parametric correlations.

FINDINGS

Significant correlations were found between selected spatiotemporal gait parameters and clinical questionnaires (r ranged between 0.28 and 0.79). Single limb support was the gait measure with the strongest correlation to pain (r=0.58), function (r=0.56) and quality of life.

INTERPRETATION

Spatiotemporal gait assessment for patients with spontaneous osteonecrosis of the knee correlates with the patient's level of pain and functional limitation there by adding objective information regarding the functional condition of these patients.

Evaluation of a rolling rehabilitation programme for patients with non-specific low back pain in primary care: an observational cohort study

AIM

The Back Rehabilitation Programme (BRP) is a group exercise programme for patients with non-specific low back pain (NSLBP) that combines cognitive behavioural therapy principles and therapeutic exercise to empower patients to self-manage their condition. Poor attendance and high attrition rates resulted in changes to the format of the programme from a standard sequential approach to a continual rolling approach. The aim of this study was to evaluate the effectiveness of this new approach on patient outcomes and its impact on attendance rates.

METHOD

A service evaluation, using a retrospective, observational cohort design, of all patients with NSLBP who attended the BRP during a 12-month period was undertaken. Outcome measures used were as follows: Bournemouth Questionnaire (BQ); fitness tests: sit to stand test, step test and walk test (taken at baseline and post programme); and attendance (taken post programme).

RESULTS

Of the patients, 56% had an improved BQ score ≥ 47%, indicating a clinically significant change. Inferential testing showed statistically significant improvements in the BQ and all three fitness tests post programme (P< 0.0001). In total, 62 patients attended the rolling BRP, and 41 patients (66%) completed. Thus, the percentage of patients completing the new programme had doubled compared with the original standard programme.

CONCLUSION

Patients with NSLBP who attended the continual rolling BRP show clinical and statistical improvements. The rolling format also appeared to enhance patient attendance. As such, the rolling BRP should be considered by practitioners as an effective management strategy when treating patients with NSLBP.

Assessing physical functioning on pain management programmes: the unique contribution of directly assessed physical performance measures and their relationship to self-reports

Physical functioning is a recommended outcome domain for pain management programmes. It can be assessed by self-report and by direct assessment of performance. Although physical performance measures may provide unique and useful information about patient functioning over and above self-report measures, it is not entirely clear which of the many possible performances to assess. This study investigated a battery of three directly assessed physical performance measures and their relationship to three currently used self-report measures of general health and functioning. The three performance measures were sensitive to treatment; patients performed significantly better on all three measures following completion of the pain management programme. The three performance measures were shown to represent a single underlying dimension, and there was a significant degree of overlap between them. The performance measures were shown to be relevant in explaining variation in the self-report measures, as well as to offer a clinically relevant different dimension of assessment to self-report. Future research could focus on developing performance-based measures that capture quality of movement and that are sensitive to relevant processes of therapeutic change.

Using Video Assessment for Clients with Chronic Low Back Pain: Is it Reliable?

Clients with chronic back pain can benefit from learning strategies to manage their pain. In a 3-week pain management programme, the use of a videotaped assessment on admission and at discharge enables occupational therapists to score functional movement, as well as providing visual feedback for the clients, although evidence of reliability is necessary. This study investigated the reliability of intrarater and interrater scoring between four experienced occupational therapists who scored the video assessment.

Forty clients and forty controls were chosen to complete the assessment. The assessment consists of tasks with 59 different items to score. Each task is scored on three factors: posture, problem solving and movement.

The results demonstrated that interrater reliability for problem solving was not consistent. However, it was consistent for posture and movement in the client group, although less so for controls, showing increased difficulty in identifying the more subtle principles being used.

Intrarater reliability was less convincing, with the therapist reporting fatigue at the number of items to be scored. However, this could be improved by reducing the number of items in the assessment because analysis showed that 39% of items did not meet the criteria for statistical significance of change. More clarification on the score measures will assist in measuring the efficacy of the treatment programme objectively.

Discriminant validity of the scoring system was indicated by the improvement seen in the clients' performance but not in that of the controls. Further studies to improve reliability and demonstrate better validity are planned.

There is no Shame in Pain: Coping and Functional Ability in Adolescents with Sickle Cell Disease

Despite the tremendous resilience of children with sickle cell anemia, this chronic illness has a significant impact in adaptation in every major area of functioning—personal care, emotional, recreational, educational, and vocational. Assessment of functional ability may help us to develop a fuller understanding of the relationships among illness severity, pain, physical dysfunction, and psychosocial adjustment in this group. A major challenge in the assessment of sickle cell disease (SCD) pain still lies in finding a reliable behavior referent of pain. Unlike the experience in other pain states (procedure-related pain), physical impairment and functional disability are salient characteristics in chronic SCD pain and, therefore, may contribute significantly to evaluations of pain states (pain ratings, pain characteristics, and pain quality). This article seeks to explore the utility of functional ability as an index of pain and pain behavior in children and adolescents with sickle cell anemia.

The usability of six physical performance tasks in a rehabilitation population with chronic low back pain

Objective: To examine the influence of task experience on the difference between test and retest and to assess test-retest reliability and limits of agreement of six performance tasks in chronic low back pain patients. These measures will be used to define the clinical usability.

Design: Test-retest of six performance tasks in a group of patients with no experience and a group of patients after previous experience with these tasks.

Setting: Three rehabilitation centres.

Subjects: Fifty-three patients with non-specific chronic low back pain.

Main measures: Five-minute walking, 50-ft (15 m) fast walking, sit-to-stand, loaded forward reach, 1-min stair-climbing and Progressive Isoinertial Lifting Evaluation (PILE). To assess the influence of task experience, differences between test and retest between both groups were tested using Mann-Whitney test. For both groups together, intraclass correlation coefficients (ICCs) and the limits of agreement using Bland and Altman plots were calculated.

Results: Thirty patients with no task experience and 23 patients who had already undertaken the tasks on at least two occasions participated. Both groups showed similar differences between test and retest. The test-retest reliability for the total study population was good to very high: ICC varied from 0.74 to 0.99. For the total study population, the limits of agreement expressed as percentage of the mean score of each task was low to moderate for 5-min walking and 1-min stair-climbing (21% and 20% respectively), moderate for 50-ft (15 m) fast walking, sit-to-stand and forward reach (33%, 29% and 36% respectively) and high for the PILE (48%).

Conclusions: Task experience did not significantly influence test-retest differences. All tasks showed sufficient test-retest reliability. Based on the natural variability of the tasks, the 5-min walking and stair-climbing task, and to a lesser degree the 50-ft (15 m) walking, sit-to-stand and loaded forward reach, seem clinically useful. There are major concerns about the usability of the PILE.

Improvements in cognition, quality of life, and physical performance with clinical Pilates in multiple sclerosis: a randomized controlled trial

[Purpose] The aim of this study was to determine the effects of clinical Pilates in multiple sclerosis patients. [Subjects and Methods] Twenty multiple sclerosis patients were enrolled in this study. The participants were divided into two groups as the clinical Pilates and control groups. Cognition (Multiple Sclerosis Functional Composite), balance (Berg Balance Scale), physical performance (timed performance tests, Timed up and go test), tiredness (Modified Fatigue Impact scale), depression (Beck Depression Inventory), and quality of life (Multiple Sclerosis International Quality of Life Questionnaire) were measured before and after treatment in all participants. [Results] There were statistically significant differences in balance, timed performance, tiredness and Multiple Sclerosis Functional Composite tests between before and after treatment in the clinical Pilates group. We also found significant differences in timed performance tests, the Timed up and go test and the Multiple Sclerosis Functional Composite between before and after treatment in the control group. According to the difference analyses, there were significant differences in Multiple Sclerosis Functional Composite and Multiple Sclerosis International Quality of Life Questionnaire scores between the two groups in favor of the clinical Pilates group. There were statistically significant clinical differences in favor of the clinical Pilates group in comparison of measurements between the groups. Clinical Pilates improved cognitive functions and quality of life compared with traditional exercise. [Conclusion] In Multiple Sclerosis treatment, clinical Pilates should be used as a holistic approach by physical therapists.

The development and delivery of a female chronic pelvic pain management programme: a specialised interdisciplinary approach

CONTEXT/BACKGROUND

Chronic pelvic pain (CPP) is a physically and psychologically debilitating condition. European Association of Urology (EAU) Guidelines (2013) and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines (2012) place strong emphasis upon multi-speciality assessment and liaison, as well as interdisciplinary assessment and intervention in reference to the management of CPP.

OBJECTIVES

The aim was to introduce and describe the development and delivery of an interdisciplinary pain management programme (PMP), at a Specialised Pain Management Centre in Liverpool, United Kingdom, for women diagnosed with CPP.

METHOD

The format and content of the CPP PMP at The Walton Centre, Liverpool, is described and the preliminary results from the CPP PMP are presented.

RESULTS

Preliminary data suggest that outcomes on the specialised CPP PMP indicate that patients are able to make clinically important change across a range of outcome measures. Moreover, these results compare favourably to the established PMP for generalised chronic pain when comparing clinically significant outcomes with the Walton Centre's (a tertiary-level pain management centre) 2013 PMP Audit document. Patients attending the CPP PMP positively appraised the PMP and felt it was useful and supportive to be in a group dedicated to CPP.

CONCLUSIONS

This article presents some preliminary results that suggest there is value in delivering a specialised multidisciplinary PMP for this group. There is a clear need for further clinical research into the effectiveness of similar interventions for CPP, including the early identification of those CPP patients who may benefit from both multi-specialty and interdisciplinary management.

Clinical effectiveness of a residential pain management programme - comparing a large recent sample with previously published outcome data

OBJECTIVE

Observational studies using routinely collected data indicate that pain management programmes (PMPs) based on cognitive-behavioural principles are associated with clinically meaningful improvements for individuals with chronic pain. This study evaluated change across functional measures in a sample of chronic pain patients attending a 4-week residential PMP between 2006 and 2010. The findings were directly compared with published outcomes from an earlier period (1989-1998) at the same service.

METHODS

Participants included 760 consecutive completers of a multidisciplinary PMP. Data were collected at pre-PMP, post-PMP (1-month post-discharge) and at a 9-month follow-up session. Group-based treatment effects and the reliability and clinical significance of change across functional measures were calculated and compared across cohorts.

RESULTS

Effect sizes for the recent cohort ranged from small to medium (.43-.67) for pain and physical functioning outcomes to large (.90-1.12) for psychological outcomes at post-treatment (n = 654), and from small (.30-.51) to medium (.58-.71) at 9-month follow-up (n = 493). Clinically significant gains on pain and psychological measures were achieved by 19-55% of patients at post-treatment and 17-44% at follow-up. Comparisons with the earlier cohort showed significantly stronger post-treatment outcomes but differences at follow-up were less marked.

DISCUSSION

These results add to the evidence base supporting the effectiveness of cognitive-behavioural therapy (CBT)-based pain management interventions. There were significantly larger gains in patient functioning in the recent dataset, suggesting improved programme delivery. But effects were less marked in the longer term, indicating a need for improvements in therapeutic models and related methods to promote meaningful and lasting changes.

Chronic Pain-related Disability: Current Scientific Rationale and Recommendations for Practice

The present paper concerns the prevention and management of disability due to chronic pain. The problem of disabling chronic pain is presented and the impact on the community is highlighted. The scientific rationale for current approaches to management is discussed and the available empirical evidence reviewed. In particular, the present paper advocates application of the biopsychosocial model for the prevention and management of chronic pain-related disability. As such, the components of the biopsychosocial model are reviewed and recommendations for rehabilitation counselling practice are presented.

Assessment of anticancer-treatment outcome in patients with metastatic castration-resistant prostate cancer-going beyond PSA and imaging, a systematic literature review

BACKGROUND

In the past years, there has been significant progress in anticancer drug development for patients with metastatic castration-resistant prostate cancer (CRPC). However, the current instruments to assess clinical treatment response have limitations and may not sufficiently reflect patient benefit. Our objective was to systematically identify tools to evaluate both patient benefit and clinical anticancer-treatment response as basis for an international consensus process and development of a specific pragmatic instrument for men with CRPC.

METHODS

PubMed, Embase and CINAHL were searched to identify currently available tools to assess anticancer-treatment benefit, other than standard imaging procedures and prostate-specific antigen measurements, namely quality of life (QoL), detailed pain assessment, physical function and objective measures of other complex cancer-related syndromes in patients with CRPC. Additionally, all CRPC phase III trials published in the last 5 years were reviewed as well as studies using physical function tools in a general cancer population. The PRIMSA statement was followed for the systematic review process.

RESULTS

The search generated 1096 hits, 185 full-text papers were screened and finally 73 publications were included. Additional 89 publications were included by hand-search. We identified a total of 98 tools used in CRPC trials and grouped these into three categories: 22 tools assessing QoL domains and subgroups, 47 tools for pain assessment and 29 tools for objective measures, mainly physical function and assessment of skeletal disease burden.

CONCLUSION

A wide variety of assessment tools and also efforts to standardize and harmonize patient-reported outcomes and pain assessment were identified. However, the specific needs of the increasing CRPC population living longer with their incurable cancer are insufficiently captured and objective physical outcome measures are under-represented. In the age of new anticancer drug targets and principles, new methods to monitor patient relevant outcomes of antineoplastic therapy are of utmost importance.

Patients with chronic non-specific low back pain who reported reduction in pain and improvement in function also demonstrated an improvement in gait pattern

PURPOSE

To assess the changes in gait pattern and clinical symptoms of patients with chronic non-specific low back pain (CNSLBP) following a home-based biomechanical treatment (HBBT).

METHODS

This was a retrospective analysis of 60 CNSLBP patients. All patients underwent a gait evaluation and completed self-assessment questionnaires at pre-treatment and after 3 and 6 months of a HBBT (AposTherapy). Twenty-four healthy, aged-matched individuals served as a reference group.

RESULTS

Significant differences were found in all gait parameters and clinical symptoms between patients with CNSLBP and healthy people before treatment. Significant improvements were found in all gait parameters and clinical measures following 6 months of therapy including an increase in gait velocity (10.6 %), step length (5.6 %), cadence (5 %), and quality of life and a decrease in pain (13.3 %). There were no significant differences between groups in the gait parameters following 6 months of treatment.

CONCLUSIONS

Significant differences exist between patients with CNSLBP and healthy controls in terms of gait pattern and self-assessed health status. The examined HBBT led to significant improvements in gait pattern, reduction in pain, improved function and increased quality of life. However, future studies should validate these results while comparing this treatment to other treatment modalities.

Different patterns of morphological changes in the hippocampus and dentate gyrus accompany the differential expression of disability following nerve injury

Physical and psychological trauma which results in mood disorders and the disruption of complex behaviours is associated with reductions in hippocampal volume. Clinical evaluation of neuropathic pain reveals mood and behavioural change in a significant number of patients. A rat model of neuropathic injury results in complex behavioural changes in a subpopulation (~30%) of injured rats; these changes are co-morbid with a range of other 'disabilities'. The specific objective of this study was to determine in rats the morphology of the hippocampus and dentate gyrus in individuals with and without complex behavioural disruptions following a constriction injury of the sciatic nerve, and to determine whether rats that develop disabilities following nerve injury have a reduced hippocampal volume compared with injured rats with no disabilities. The social behaviours of nerve-injured rats were evaluated before and after nerve injury. The morphology of the hippocampus of rats with and without behavioural disruptions was compared in serial histological sections. Single-housing and repeated social-interaction testing had no effect on the morphology of either the hippocampus or the dentate gyrus. Rats with transient or ongoing disability identified by behavioural disruption following sciatic nerve injury, show bilateral reductions in hippocampal volume, and lateralised reduction in the dentate gyrus (left side). Disabled rats display a combination of behavioural and physiological changes, which resemble many of the criteria used clinically to diagnose mood disorders. They also show reductions in the volume of the hippocampus similar to people with clinically diagnosed mood disorders. The sciatic nerve injury model reveals a similarity to the human neuropathic pain presentation presenting an anatomically specific focus for the investigation of the neural mechanisms underpinning the co-morbidity of chronic pain and mood disorder.

Several submaximal exercise tests are reliable, valid and acceptable in people with chronic pain, fibromyalgia or chronic fatigue: a systematic review

QUESTION

Are submaximal and maximal exercise tests reliable, valid and acceptable in people with chronic pain, fibromyalgia and fatigue disorders?

DESIGN

Systematic review of studies of the psychometric properties of exercise tests.

PARTICIPANTS

People older than 18 years with chronic pain, fibromyalgia and chronic fatigue disorders.

INTERVENTION

Studies of the measurement properties of tests of physical capacity in people with chronic pain, fibromyalgia or chronic fatigue disorders were included.

OUTCOME MEASURES

Studies were required to report: reliability coefficients (intraclass correlation coefficient, alpha reliability coefficient, limits of agreements and Bland-Altman plots); validity coefficients (intraclass correlation coefficient, Spearman's correlation, Kendal T coefficient, Pearson's correlation); or dropout rates.

RESULTS

Fourteen studies were eligible: none had low risk of bias, 10 had unclear risk of bias and four had high risk of bias. The included studies evaluated: Åstrand test; modified Åstrand test; Lean body mass-based Åstrand test; submaximal bicycle ergometer test following another protocol other than Åstrand test; 2-km walk test; 5-minute, 6-minute and 10-minute walk tests; shuttle walk test; and modified symptom-limited Bruce treadmill test. None of the studies assessed maximal exercise tests. Where they had been tested, reliability and validity were generally high. Dropout rates were generally acceptable. The 2-km walk test was not recommended in fibromyalgia.

CONCLUSION

Moderate evidence was found for reliability, validity and acceptability of submaximal exercise tests in patients with chronic pain, fibromyalgia or chronic fatigue. There is no evidence about maximal exercise tests in patients with chronic pain, fibromyalgia and chronic fatigue.

A comprehensive examination of the model underlying acceptance and commitment therapy for chronic pain

The therapeutic model underlying Acceptance and Commitment Therapy (ACT) is reasonably well-established as it applies to chronic pain. Several studies have examined measures of single ACT processes, or subsets of processes, and have almost uniformly indicated reliable relations with patient functioning. To date, however, no study has performed a comprehensive examination of the entire ACT model, including all of its component processes, as it relates to functioning. The present study performed this examination in 274 individuals with chronic pain presenting for an assessment appointment. Participants completed a battery of self-report questionnaires, assessing multiple aspects of the ACT model, as well as pain intensity, disability, and emotional distress. Initial exploratory factor analyses examined measures of the ACT model and measures of patient functioning separately with each analysis identifying three factors. Next, the fit of a model including ACT processes on the one hand and patient functioning on the other was examined using Structural Equation Modeling. Overall model fit was acceptable and indicated moderate correlations among the ACT processes themselves, as well as significant relations with pain intensity, emotional distress, and disability. These analyses build on the existing literature by providing, to our knowledge, the most comprehensive evaluation of the ACT theoretical model in chronic pain to date.

Intensive, progressive exercise improves quality of life following lumbar microdiskectomy: a randomized controlled trial

Objective:

The purpose of the study was to examine changes in quality of life measures in patients who have undergone an intensive exercise program following a single level microdiskectomy.

Design:

Randomized controlled trial with blinded examiners.

Setting:

The study was conducted in outpatient physical therapy clinics.

Subjects:

Ninety-eight participants (53 male, 45 female) who had undergone a single-level lumbar microdiskectomy allocated to receive exercise and education or education only.

Interventions:

A 12-week periodized exercise program of lumbar extensor strength and endurance training, and mat and upright therapeutic exercises was administered.

Outcome measures:

Quality of life was tested with the Short Form 36 (SF-36). Measurements were taken 4–6 weeks postsurgery and following completion of the 12-week intervention program. Since some participants selected physical therapy apart from the study, analyses were performed for both an as-randomized (two-group) design and an as-treated (three-group) design.

Results:

In the two-group analyses, exercise and education resulted in a greater increase in SF-36 scales, role physical (17.8 vs. 12.1) and bodily pain (13.4 vs. 8.4), and the physical component summary (13.2 vs. 8.9). In the three-group analyses, post-hoc comparisons showed exercise and education resulted in a greater increase in the SF-36 scales, physical function (10.4 vs. 5.6) and bodily pain (13.7 vs. 8.2), and the physical component summary (13.7 vs. 8.9) when compared with usual physical therapy.

Conclusions:

An intensive, progressive exercise program combined with education increases quality of life in patients who have recently undergone lumbar microdiskectomy.