Global rating of change: perspectives of patients with lumbar impairments and of their physical therapists

Multi-site evaluation of advanced practice hand therapy clinics for the management of patients with trigger digit

STUDY DESIGN

Prospective cohort design.

BACKGROUND

Patient time on Australian public hospital surgical outpatient department (SOPD) waitlists often exceeds clinical recommendations for chronic hand conditions. Diversion to allied health is an alternative option, however evidence regarding patient and organizational outcomes in hand therapy is lacking.

PURPOSE OF THE STUDY

To evaluate clinical and organizational efficacy, patient outcomes and satisfaction of diversion of referrals for patients with trigger digit (TD) from SOPD waitlists to Advanced Practice Hand Therapy (APHT) at 3 Australian hospitals.

METHODS

Data was collected from eligible patients with TD through chart reviews and telephone satisfaction surveys. Data included number of patients requiring SOPD review, repeat referral to SOPD in the 12 months following APHT discharge, patient-rated outcomes, satisfaction scores, wait times to SOPD review and conversion to surgery-rates. Mann Whitney-U, t-test, Pearson's chi-squared test and a Binary Logistic Regression analysis were performed.

RESULTS

104 patients completed APHT treatment. Seventy patients (67%) did not require return to the SOPD waitlist. Repeat referral to SOPD within 12 months of APHT discharge occurred for only 1 patient. Patients requiring SOPD review after APHT treatment were seen within target time frames and demonstrated 88% conversion to surgery-rates. Michigan Hand Outcome Questionnaire scores showed greater improvement in those not requiring SOPD review (P< .001~25.9 vs 4.2). Regression analysis identified a negative association between initial total Michigan Hand Outcome Questionnaire scores and unfavorable discharge outcomes (OR 0.96, P= .007). Most (81%-93%) patients indicated satisfaction with the APHT service.

CONCLUSION

Diversion of referrals for TD from SOPD to APHT is an effective waitlist management strategy, with the propensity to reduce waiting times, improve patient flow, whilst resulting in favorable clinical and patient-rated outcomes and satisfaction.

Effect of thermal therapy and exercises on acute low back pain: a protocol for a randomized controlled trial

BACKGROUND

Low back pain (LBP) is the first cause of years lived with disability worldwide. This is due to the development of chronic pain. Thus, it is necessary to identify the best therapeutic approaches in the acute phase of LBP to limit the transition to chronic pain. Superficial heat presents the highest level of evidence for short-term reduction in pain and disability in acute LBP. Physical activity is also recommended to avoid transition to chronic LBP, but there is a lack of evidence to determine its effect to reduce acute LBP. Also, the long-term effects of these interventions are unknown. This is a protocol for a randomized controlled trial (RCT) to determine the short and long-term effects of wearable continuous low-level thermal therapy, in combination with exercises or not, on disability and pain.

METHODS/DESIGN

Sixty-nine participants with acute LBP will be randomly assigned to one of three intervention programs: 1) thermal therapy, 2) thermal therapy + exercises, and 3) control. The interventions will be applied for 7 continuous days. The primary outcome will be disability and secondary outcomes will be pain intensity, pain-related fear, self-efficacy, number of steps walked and perception of change. The evaluators will be blinded to the interventions, and participants will be blinded to other groups' interventions. Primary and secondary outcomes will be compared between intervention groups.

DISCUSSION

This study will provide new evidence about acute LBP treatments, to limit transition to chronicity. This will be the first study to measure the long-term effects of wearable continuous low-level thermal therapy, combined or not to exercises.

TRIAL REGISTRATION

This RCT has been retrospectively registered on ClinicalTrials.gov ( NCT03986047 ) on June 14th, 2019.

Psychometric properties of the global rating of change scales in patients with low back pain, upper and lower extremity disorders. A systematic review with meta-analysis

Objective

The purpose of this systematic review was to critically appraise and synthesize the psychometric properties of the Global Rating of Change (GRoC) scales on the assessment of patients with low back pain (LBP), upper extremity and lower extremity disorders.

Methods

A search was performed in 4 databases (MEDLINE, EMBASE, CINAHL, SCOPUS) until February 2019. Eligible articles were appraised using Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist and the Quality Appraisal for Clinical Measurement Research Reports Evaluation Form.

Results

The 8 eligible studies included participants with orthopedic lumbar spine impairments (n = 52,767), patients with work-related musculoskeletal disorders (n = 1944), patients with low back pain (n = 183) and individuals with upper extremity disorders (n = 151). Risk of bias was ranging from "adequate" to "very good" and quality was found excellent for all studies. Based on pooled data, test-retest reliability of 11-item GRoC for patients with low back pain was found excellent ICC = 0.84, 95% CI: 0.65 to 0.94. Test-retest reliability in patients with shoulder pain was found fair to good ICC of 0.62 in a 15-point GRoC scale. Seven studies (n = 7) examined the convergent validity between GRoC and another outcome measure. Minimum important change on the Portuguese version of Global Perceived Effect (GPE) for patients with LBP was 2.5 points out of 11 points.

Conclusions

The current pool of clinical measurement studies indicates that the GRoC has excellent test-retest reliability for patients with low back pain, shoulder pain and with lumbar spine disorders. However, the validity of it as a reference standard in responsiveness studies or as an accurate overall assessment of change has been questioned. While future studies might provide more insight into its measurement properties, this limitation is unlikely to change. Therefore, we suggest that future responsiveness in the studies that want a global indicator measure need to use an additional measure to mitigate recall bias.

Prospero registration number

CRD 42020149122.

"Minimal clinically important difference" estimates of 6 commonly-used performance tests in patients with chronic musculoskeletal pain completing a work-related multidisciplinary rehabilitation program

Background

Functional tests are widely used to measure performance in patients with chronic musculoskeletal pain. Our objective was to determine the Minimal Clinically Important Differences (MCID) for the 6-min walk test (6MWT), the Steep Ramp Test (SRT), the 1-min stair climbing test (1MSCT), the sit-to-stand test (STS), the Jamar dynamometer test (JAM) and the lumbar Progressive Isoinertial Lifting Evaluation (PILE) in chronic musculoskeletal pain patients.

Methods

A single-center prospective observational study was conducted in a rehabilitation center. Patients with upper-limb, lower-limb or neck/back lesions were included over a period of 21 months. We used the anchor-based method as a reference method, supplemented by the distribution-based and opinion-based approaches, to determine the MCIDs.

Results

838 chronic musculoskeletal pain patients were included. The estimation method and thelesion location had a significant influence on the results. MCIDs were estimated at +75m and +60m for the 6MWT (lower-limb and neck/back lesions, respectively), +18 steps for the 1MSCT (lower-limb and neck/back lesions) and +6kg for the JAM (upper limb lesions). The anchor-based method could not provide valid estimations for the three other scales, but distribution and opinion-based methods provided rough values of MCIDs for the SRT (+39w to +61w), the STS (-5 sec to -7 sec) and the PILE (+4kg to +7kg).

Conclusion

The above MCID estimations for the 6MWT, 1MSCT and JAM can be used in chronic musculoskeletal pain patients participating in vocational multidisciplinary rehabilitation programs or in therapeutic trials. The use of specific anchors might give better estimations of MCIDs for the three other scales in future research.

Removing the Mask of Average Treatment Effects in Chronic Lyme Disease Research Using Big Data and Subgroup Analysis

Lyme disease is caused by the bacteria borrelia burgdorferi and is spread primarily through the bite of a tick. There is considerable uncertainty in the medical community regarding the best approach to treating patients with Lyme disease who do not respond fully to short-term antibiotic therapy. These patients have persistent Lyme disease symptoms resulting from lack of treatment, under-treatment, or lack of response to their antibiotic treatment protocol. In the past, treatment trials have used small restrictive samples and relied on average treatment effects as their measure of success and produced conflicting results. To provide individualized care, clinicians need information that reflects their patient population. Today, we have the ability to analyze large data bases, including patient registries, that reflect the broader range of patients more typically seen in clinical practice. This allows us to examine treatment variation within the sample and identify groups of patients that are most responsive to treatment. Using patient-reported outcome data from the MyLymeData online patient registry, we show that sub-group analysis techniques can unmask valuable information that is hidden if averages alone are used. In our analysis, this approach revealed treatment effectiveness for up to a third of patients with Lyme disease. This study is important because it can help open the door to more individualized patient care using patient-centered outcomes and real-world evidence.