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Beneciuk JM, Michener LA, Sigman E, Harrison T, Buzzanca-Fried KE, Lu X, Shan G, Hill JC. Validation of the Keele STarT MSK Tool for Patients With Musculoskeletal Pain in United States-based Outpatient Physical Therapy Settings. THE JOURNAL OF PAIN 2024; 25:104475. [PMID: 38242334 DOI: 10.1016/j.jpain.2024.01.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/21/2024]
Abstract
The STarT MSK tool was developed to enable risk stratification of patients with common musculoskeletal (MSK) pain conditions and help identify individuals who may require more targeted interventions or closer monitoring in primary care settings, however, its validity in U.S.-based outpatient physical therapy settings has not been investigated. The 10-item Keele STarT MSK risk stratification tool was tested for construct (convergent and discriminant) and predictive validity using a multicenter, prospective cohort study design. Participants (n = 141) receiving physical therapy for MSK pain of the back, neck, shoulder, hip, knee, or multisite regions completed intake questionnaires including the Keele STarT MSK tool, Functional Comorbidity Index (FCI), Optimal Screening for Prediction of Referral and Outcome Review-of-Systems and Optimal Screening for Prediction of Referral and Outcome Yellow Flag tools. Pain intensity, pain interference, and health-related quality of life (Medical Outcomes Study 8-item Short-Form Health Survey (SF-8) physical [PCS] and mental [MCS] component summary scores) were measured at 2- and 6-month follow-up. Participants were classified as STarT MSK tool low (44%), medium (39%), and high (17%) risk. Follow-up rates were 70.2% (2 months) and 49.6% (6 months). For convergent validity, fair relationships were observed between the STarT MSK tool and FCI and SF-8 MCS (r = .35-.37) while moderate-to-good relationships (r = .51-.72) were observed for 7 other clinical measures. For discriminant validity, STarT MSK tool risk-dependent relationships were observed for Optimal Screening for Prediction of Referral and Outcome Review-of-Systems, Optimal Screening for Prediction of Referral and Outcome Yellow Flag, pain interference, and SF-8 PCS (low < medium < high; P < .01) and FCI, pain intensity, and SF-8 MCS (low < medium-or-high; P < .01). For predictive validity, intake STarT MSK tool scores explained additional variability in pain intensity (11.2%, 20.0%), pain interference (7.5%, 14.1%), and SF-8 PCS (8.2%, 12.8%) scores at 2 and 6 months, respectively. This study contributes to the existing literature by providing additional evidence of STarT MSK tool cross-sectional construct validity and longitudinal predictive validity. PERSPECTIVE: This study presents STarT MSK risk stratification tool validity findings from a U.S. outpatient physical therapy sample. The STarT MSK tool has the potential to help physical therapists identify individuals presenting with the most common MSK pain conditions who may require more targeted interventions or closer monitoring.
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Affiliation(s)
- Jason M Beneciuk
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Gainesville, Florida; Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida
| | - Lori A Michener
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California
| | - Erica Sigman
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California
| | - Trent Harrison
- Brooks Institute of Higher Learning, Brooks Rehabilitation, Jacksonville, Florida
| | - Katherine E Buzzanca-Fried
- Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida; Rehabilitation Science Doctoral Program, College of Public Health & Health Professions, University of Florida, Gainesville, Florida
| | - Xinlin Lu
- Department of Biostatistics, University of Florida, Gainesville, Florida
| | - Guogen Shan
- Department of Biostatistics, University of Florida, Gainesville, Florida
| | - Jonathan C Hill
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
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Quek JMT, Tan J, Toh I, Chen JLT, Yeo W, Pua YH. Time course and correlates of psychological distress post spinal surgery: A longitudinal study. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100277. [PMID: 37869544 PMCID: PMC10589875 DOI: 10.1016/j.xnsj.2023.100277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 10/24/2023]
Abstract
Background Psychological distress post lumbar spine surgery is associated with poorer outcomes. There is a scarcity of studies devoted to analyzing the risk factors associated with psychological distress in patients who have undergone lumbar fusion surgery. The purpose of this study was to (1) describe the time course and severity of psychological distress using the STarT Back Tool (SBT) and (2) determine the demographic and clinical predictors of SBT score post lumbar spine fusion surgery. Methods This retrospective longitudinal study analyzed 227 subjects with 1- and 2-level lumbar fusion surgery who underwent standardized assessment preoperatively and at 4 and 12 weeks postoperatively. Preoperative variables collected were demographic, clinical, and psychological variables. Postoperative psychological distress was measured by self-reported SBT. Risk factors for SBT over time were identified using ordinal and mixed-effects modelling. Results Although the trajectory of SBT levels declined postoperatively over time, at week-12, 20% of patients had moderate to high SBT. Postoperative SBT scores at week-4 time point was significantly greater than SBT scores at week-8 (OR = 2.7, 95% credible interval [CrI]; 1.8-3.9). Greater SBT scores at week-4 were strongly associated with greater SBT scores throughout 12 weeks of follow-up (OR = 7.3, [95% CrI; 1.2-31.4]). Greater postoperative SBT levels over time were associated with being male (OR = 2.2, 95% CrI; 1.0-3.9), greater preoperative back or leg pain intensity (OR = 2.2; 95% CrI: 1.0-4.4), greater preoperative leg weakness (OR = 4.2, 95% CrI: 1.7-7.5) and higher preoperative depression levels (OR = 4.8; 95% CrI: 1.6-10.4). Conclusion Postoperative SBT levels declined nonlinearly over time. However, a sizable proportion of patients had moderate to high psychological distress at week-12 postsurgery. Greater preoperative back or leg pain intensity, leg weakness and depression levels, and male gender were risk factors of greater psychological distress postsurgery. Although requiring validation, our study has identified potential modifiable risk factors which may give an opportunity to provide early (preoperative) and targeted strategies to optimize postoperative psychosocial outcomes in patients undergoing lumbar fusion surgeries.
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Affiliation(s)
- June Mei Tse Quek
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore 169608
| | - Joy Tan
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore 169608
| | - Irene Toh
- Allied Health Centre of Excellence, The National Trades Union Congress Health Co-Operative Ltd., Singapore, 5 Ubi Ave 1, #08-01, Singapore 408935
| | - John Li-Tat Chen
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, Singapore 169608
| | - William Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, Singapore 169608
| | - Yong-Hao Pua
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore 169608
- Medicine Academic Programme, Duke-NUS Graduate Medical School, Singapore General Hospital, Outram Road, Singapore 169608
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Fang Y, Chen J, Lin S, Cai Y, Huang LH. Predictive performance of the STarT Back tool for poor outcomes in patients with low back pain: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e069818. [PMID: 37562930 PMCID: PMC10423782 DOI: 10.1136/bmjopen-2022-069818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/21/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION Subgroups for Targeted Treatment Back Tool (SBT) is a brief multiple-construct risk prediction tool for patients with low back pain (LBP). Thus far, the predictive ability of this tool has been inconsistent. Therefore, we aim to conduct a literature review on the predictive ability of the SBT to determine the outcomes of patients with LBP. The results of this review should improve the ability of the SBT to predict poor outcomes in patients with LBP. METHODS AND ANALYSIS Databases including PubMed, EMBASE, Cochrane Central, Web of Science, Chinese National Knowledge Infrastructure Databases, Chinese Science and Technology Journal Database, and Wanfang will be searched for studies on SBT and LBP from their inception until 31 March 2023. Longitudinal studies investigating the association between SBT subgroups and LBP outcomes, including pain, disability and quality of life, will be included. The identified studies will be independently screened for eligibility by two reviewers. A standardised sheet will be used to extract data. The Newcastle-Ottawa Scale will be used to assess the methodological quality of the included studies. Heterogeneity will be evaluated by the χ2 test with Cochran's Q statistic and quantified by the I2 statistic. The results will be synthesised qualitatively and presented as pooled risk ratios or beta coefficients quantitatively. The results will also be presented using their 95% confidence limits. Publication bias will be assessed using the method proposed by Egger and by visual inspection of funnel plots. ETHICS AND DISSEMINATION This study is a secondary analysis of original studies that received ethics approval. Therefore, prior ethical approval is not required for this study. The findings will be submitted to relevant peer-reviewed journals for publication and presented at profession-specific conferences. TRIAL REGISTRATION NUMBER PROSPERO registration numberCRD42022309189.
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Affiliation(s)
- Yunhua Fang
- Rehabilitation medicine department, Fujian Provincial Hospital, Fuzhou, China
- Rehabilitation medicine department, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jie Chen
- Rehabilitation medicine department, Fujian Provincial Hospital, Fuzhou, China
| | - Shengmei Lin
- Rehabilitation medicine department, Fujian Provincial Hospital, Fuzhou, China
| | - Yangfan Cai
- Encephalopathy rehabilitation fifth department, Rehabilitation Hospital affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
- Fujian Key Laboratory of Rehabilitation Technology, Fuzhou, China
| | - Lian-Hong Huang
- Rehabilitation medicine department, Fujian Provincial Hospital, Fuzhou, China
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Recurrence of an Episode of Low Back Pain: An Inception Cohort Study in Emergency Departments. J Orthop Sports Phys Ther 2022; 52:484-492. [PMID: 35584012 DOI: 10.2519/jospt.2022.10775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To (1) determine the 1-year estimate of recurrence of low back pain (LBP) in a cohort of people presenting to emergency departments who have recently recovered from an episode of acute LBP in a middle-income country, (2) estimate a recurrence of LBP stratified by the STarT Back Screening Tool (SBST), and (3) determine prognostic factors for the recurrence of LBP. DESIGN Prospective inception cohort study. METHODS We included 238 patients who presented to emergency departments with recent-onset nonspecific LBP in São Paulo, Brazil. The outcome was the recurrence of an episode of LBP, assessed using 2 definitions: (1) 12-month recall alone and (2) pain measurements at follow-up. Prognostic factors were determined by logistic regression. RESULTS Within 1 year, the estimated recurrence of an episode of LBP ranged from 35% (79/225 events) (first definition) to 44% (100/226 events) (second definition). When patients were stratified by the SBST, the estimate of recurrence ranged from 29% to 37% (21-27/73 events) for low-risk patients, from 33% to 39% (24-28/72 events) for medium-risk patients, and from 43% to 56% (34-45/80 events) for high-risk patients. Age, perceived risk of persistent LBP, and disability were independent prognostic factors associated with LBP recurrence within 1 year. CONCLUSION After recovering from a previous episode of acute LBP, 4 in every 10 patients experienced a recurrence within 1 year. This estimate varied depending on the classification used in the SBST. Within 1 year, age, perceived risk of persistent LBP, and baseline disability were predictors of recurrence. J Orthop Sports Phys Ther 2022;52(7):484-492. Epub: 18 May 2022. doi:10.2519/jospt.2022.10775.
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de Souza BL, de Souza PC, Ribeiro AP. Effect of low back pain on clinical-functional factors and its associated potential risk of chronicity in adolescent dancers of classical ballet: cross-sectional study. BMC Sports Sci Med Rehabil 2022; 14:81. [PMID: 35501831 PMCID: PMC9063377 DOI: 10.1186/s13102-022-00474-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Low back pain (LBP) is a common symptom in classical ballet dancers, which can limit their daily activities and dance training routines. The purpose of the study was to verify the association and comparison of clinical-functional outcomes (spine flexibility and foot posture) between different levels of intensity low back pain in adolescents of classical ballet and the potential risk of chronicity using the STarT back tool. METHODS Cross-sectional study. PARTICIPANTS 78 adolescent girls who practice classical ballet were evaluated and divided into groups according to level of low back pain: mild (n = 21), moderate (n = 17), and high (n = 20), and a control group (n = 20). MAIN OUTCOME MEASURES Pain, flexibility of the spine (thoracic and lumbosacral), risk of chronicity for low back pain, and foot posture were assessed using the visual analogue scale, clinical tests, STarT back screening tool (SBST) questionnaire, and foot posture index (FPI), respectively. RESULTS Dancers with high-intensity low back pain showed a potential risk of chronicity by the SBST. The spine pain intensity was not different considering thoracic and lumbosacral flexibility in the sagittal plane, but was different with greater supine FPI when compared to control dancers. Mild low back pain was associated with greater supine FPI. The SBST score was associated with higher exposure time-frequency and time of dancing. CONCLUSION Adolescents of classical ballet with high-intensity low back pain showed a potential risk of chronicity by the SBST. The level of intensity low back pain did not influence the clinical-functional aspects of spine flexibility in the sagittal plane, but the level of intensity moderate pain promoted changes in foot posture (more supinated). The potential risk of chronicity using the SBST was also associated with higher exposure time-frequency and time of dancing, in adolescents of classical ballet.
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Affiliation(s)
- Brenda Luciano de Souza
- Biomechanics and Musculoskeletal Rehabilitation Laboratory, Health Science Post-Graduate Department, School of Medicine, University Santo Amaro, R. Professor Enéas de Siqueira Neto, 340, Campus I, São Paulo, SP, 04829-900, Brazil
| | - Patricia Colombo de Souza
- Biomechanics and Musculoskeletal Rehabilitation Laboratory, Health Science Post-Graduate Department, School of Medicine, University Santo Amaro, R. Professor Enéas de Siqueira Neto, 340, Campus I, São Paulo, SP, 04829-900, Brazil
| | - Ana Paula Ribeiro
- Biomechanics and Musculoskeletal Rehabilitation Laboratory, Health Science Post-Graduate Department, School of Medicine, University Santo Amaro, R. Professor Enéas de Siqueira Neto, 340, Campus I, São Paulo, SP, 04829-900, Brazil. .,Physical Therapy and Sport Science Department, School of Medicine, University of São Paulo, São Paulo, Brazil.
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Beneciuk JM, George SZ. Adding Physical Impairment to Risk Stratification Improved Outcome Prediction in Low Back Pain. Phys Ther 2020; 101:5911071. [PMID: 32970820 PMCID: PMC8179624 DOI: 10.1093/ptj/pzaa179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/06/2020] [Accepted: 08/16/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Identifying subgroups of low back pain (LBP) has the potential to improve prediction of clinical outcomes. Risk stratification is one such strategy that identifies similar characteristics indicative of a common clinical outcome trajectory. The purpose of this study was to determine if an empirically derived subgrouping approach based on physical impairment measures improves information provided from the STarT Back Tool (SBT). METHODS At baseline in this secondary analysis of a cohort study, patients (N = 144) receiving physical therapy for LBP completed the SBT and tests (active lumbar flexion, extension, lateral bending, and passive straight-leg raise) from a validated physical impairment index. Clinical outcomes were assessed at 4 weeks and included the Numerical Pain Rating Scale and Oswestry Disability Index. Exploratory hierarchical agglomerative cluster analysis identified empirically derived subgroups based on physical impairment measures. Independent samples t testing and chi-square analysis were used to assess baseline subgroup differences in demographic and clinical measures. Spearman rho correlation coefficient was used to assess baseline SBT risk and impairment subgroup relationships, and a 3-way mixed-model ANOVA was used to assessed SBT risk and impairment subgroup relationships with clinical outcomes at 4 weeks. RESULTS Two physical impairment-based subgroups emerged from cluster analysis: (1) low-risk impairment (n = 119, 81.5%), characterized by greater lumbar mobility; and (2) high-risk impairment (n = 25, 17.1%), characterized by less lumbar mobility. A weak, positive relationship was observed between baseline SBT risk and impairment subgroups (rs = .170). An impairment-by-SBT risk-by-time interaction effect was observed for Oswestry Disability Index scores but not for Numerical Pain Rating Scale scores at 4 weeks. CONCLUSIONS Physical impairment subgroups were not redundant with SBT risk categories and could improve prediction of 4-week LBP disability outcomes. Physical impairment subgroups did not improve the prediction of 4-week pain intensity scores. IMPACT Subgroups based on physical impairment and psychosocial risk could lead to better prediction of LBP disability outcomes and eventually allow for treatment options tailored to physical and psychosocial risk.
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Affiliation(s)
- Jason M Beneciuk
- Department of Physical Therapy, University of Florida, Gainesville, Florida; and Brooks Rehabilitation Clinical Research Center, 3901 University Boulevard South, Suite 103, Jacksonville, FL 32216, USA,Address all correspondence to Dr Beneciuk at: . @JBeneciuk
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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Use of the STarT Back Screening Tool in patients with chronic low back pain receiving physical therapy interventions. Braz J Phys Ther 2020; 25:286-295. [PMID: 32773289 DOI: 10.1016/j.bjpt.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 05/28/2020] [Accepted: 07/17/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The STarT Back Screening Tool (SBST) is used to stratify care. It is unclear if the SBST approach works as well for patients in low- and medium-income countries as for patients from high-income countries. OBJECTIVES (1) To investigate whether patients with chronic low back pain (LBP) stratified by the SBST are different at baseline; (2) to describe the clinical course for each SBST subgroup; (3) to investigate the SBST utility to predict clinical outcomes; and (4) to determine which SBST subgroup show greater clinical improvement. DESIGN This is a secondary analysis of data derived from a previously published clinical trial. METHODS 148 patients with chronic nonspecific LBP were included. Pain intensity, disability, global perceived effect, and the SBST were assessed at baseline and at 5, 12, and 24 weeks after baseline. Descriptive data were provided and ANOVA, unadjusted and adjusted regression models, and linear mixed models were used for data analysis. RESULTS Duration of symptoms, use of medication, pain, disability, and global perceived effect were different between SBST subgroups. Clinical improvements over a 6-month period were consistently greater in patients classified as high risk. The SBST was able to predict disability but this predictability decreased when the analysis was adjusted for possible confounders. CONCLUSION Clinical outcomes were different between SBST subgroups over 6 months. Adjusting for confounders influenced the predictability of SBST. Patients classified as high risk presented higher improvements in terms of disability.
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Tagliaferri SD, Angelova M, Zhao X, Owen PJ, Miller CT, Wilkin T, Belavy DL. Artificial intelligence to improve back pain outcomes and lessons learnt from clinical classification approaches: three systematic reviews. NPJ Digit Med 2020; 3:93. [PMID: 32665978 PMCID: PMC7347608 DOI: 10.1038/s41746-020-0303-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022] Open
Abstract
Artificial intelligence and machine learning (AI/ML) could enhance the ability to detect patterns of clinical characteristics in low-back pain (LBP) and guide treatment. We conducted three systematic reviews to address the following aims: (a) review the status of AI/ML research in LBP, (b) compare its status to that of two established LBP classification systems (STarT Back, McKenzie). AI/ML in LBP is in its infancy: 45 of 48 studies assessed sample sizes <1000 people, 19 of 48 studies used ≤5 parameters in models, 13 of 48 studies applied multiple models and attained high accuracy, 25 of 48 studies assessed the binary classification of LBP versus no-LBP only. Beyond the 48 studies using AI/ML for LBP classification, no studies examined use of AI/ML in prognosis prediction of specific sub-groups, and AI/ML techniques are yet to be implemented in guiding LBP treatment. In contrast, the STarT Back tool has been assessed for internal consistency, test-retest reliability, validity, pain and disability prognosis, and influence on pain and disability treatment outcomes. McKenzie has been assessed for inter- and intra-tester reliability, prognosis, and impact on pain and disability outcomes relative to other treatments. For AI/ML methods to contribute to the refinement of LBP (sub-)classification and guide treatment allocation, large data sets containing known and exploratory clinical features should be examined. There is also a need to establish reliability, validity, and prognostic capacity of AI/ML techniques in LBP as well as its ability to inform treatment allocation for improved patient outcomes and/or reduced healthcare costs.
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Affiliation(s)
- Scott D. Tagliaferri
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
| | - Maia Angelova
- School of Information Technology, Deakin University, Geelong, VIC Australia
| | - Xiaohui Zhao
- Xi’an University of Architecture & Technology, Beilin, Xi’an China
| | - Patrick J. Owen
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
| | - Clint T. Miller
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
| | - Tim Wilkin
- School of Information Technology, Deakin University, Geelong, VIC Australia
| | - Daniel L. Belavy
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
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Profile of Patients With Acute Low Back Pain Who Sought Emergency Departments: A Cross-sectional Study. Spine (Phila Pa 1976) 2020; 45:E296-E303. [PMID: 32045404 DOI: 10.1097/brs.0000000000003253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional study. OBJECTIVE The aim of this study is to describe the profile of patients with acute low back pain (LBP) who sought emergency departments (EDs) in Brazilian public hospitals. We also described the profile of these patients according to the STarT Back Screening Tool (SBST). SUMMARY OF BACKGROUND DATA LBP is the most common musculoskeletal condition worldwide and is one of the main complaints in EDs. There is a lack of evidence describing the profile of these patients from low- to middle-income countries. METHODS This is a cross-sectional study involving patients with a new episode of nonspecific acute LBP that was conducted between August 2014 and August 2016. Variables related to clinical, psychological, sociodemographic and work status characteristics were investigated through structured, in-person oral questionnaire. RESULTS A total of 600 patients were included in the study. The majority of the patients were women (58%), with a median of eight points on pain intensity (measured on an 11-point scale) and 17 points on disability (measured on a 24-item questionnaire). With regards to the SBST evaluation, 295 (49.2%) patients were classified as being at high risk of developing an unfavorable prognosis with a median pain intensity of nine points on pain intensity, 20 points on disability, and seven points on depression (measured on an 11-point scale). Despite this, the majority of the patients (74%) continued working normally without interference from LBP. CONCLUSION Identifying the profile of patients seeking care in EDs can help to define effective management for LBP in low- and middle-income countries. Patients with nonspecific acute LBP who seek EDs in Brazil present high levels of pain intensity and disability. Most patients were classified as having a high risk of developing an unfavorable prognosis. LEVEL OF EVIDENCE 2.
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A Responsiveness Analysis of the Subgroups for Targeted Treatment (STarT) Back Screening Tool in Patients With Nonspecific Low Back Pain. J Orthop Sports Phys Ther 2019; 49:725-735. [PMID: 31443624 DOI: 10.2519/jospt.2019.8776] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Subgroups for Targeted Treatment (STarT) Back Screening Tool (SBST) screens patients with low back pain and directs them to different levels of physical therapy treatment. The SBST is also used to monitor changes in a range of modifiable prognostic factors. However, the current evidence on the responsiveness of the SBST is limited. OBJECTIVES To test the responsiveness of the SBST at 6 weeks and 6 months. METHODS This measurement property study is a secondary analysis of data from 2 previous studies that included 348 participants with nonspecific low back pain. All participants were assessed at baseline, 6 weeks, and 6 months. To detect clinical changes, the SBST was compared to 3 one-dimensional constructs: global perceived effect, disability, and pain intensity. To assess responsiveness, we tested 15 specific predefined hypotheses based on correlation, effect size, and receiver operating characteristic curve analyses. If 75% or more of the hypotheses were accepted, then responsiveness was considered to be high. RESULTS Most of the hypotheses were accepted. Testing the SBST as a continuous score, 85.7% and 87.5% of the hypotheses were accepted at 6 weeks and 6 months, respectively. For medium- and high-risk subgroups, 85.7% and 87.5% of the hypotheses were accepted at 6 weeks and 6 months. The low-risk subgroup had 42.9% of the hypotheses accepted at 6 weeks and 100% of the hypotheses accepted at 6 months. CONCLUSION The SBST had high responsiveness at 6 weeks in subgroups of patients with a medium and high risk, and poor responsiveness in those with a low risk, of persistent disability. The SBST has high responsiveness in all SBST subgroups at 6 months. Clinicians can confidently use the SBST to measure changes over time in terms of subgroups. LEVEL OF EVIDENCE Longitudinal clinical measurement, level 1b. J Orthop Sports Phys Ther 2019;49(10):725-735. Epub 23 Aug 2019. doi:10.2519/jospt.2019.8776.
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Garcia AN, Costa LOP, Costa LDCM, Hancock M, Cook C. Do prognostic variables predict a set of outcomes for patients with chronic low back pain: a long-term follow-up secondary analysis of a randomized control trial. J Man Manip Ther 2019; 27:197-207. [PMID: 30946005 DOI: 10.1080/10669817.2019.1597435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022] Open
Abstract
Objective: The objective was to explore for universal prognostic variables, or predictors, across three different outcome measures in patients with chronic low back pain (LBP). We hypothesized that selected prognostic variables would be 'universal' prognostic variables, regardless of the outcome measures used. Methods: This study was a secondary analysis of data from a previous randomized controlled trial comparing the McKenzie treatment approach with placebo in patients with chronic LBP. Ten baseline prognostic variables were explored in predictive models for three outcomes: pain intensity, disability, and global perceived effect, at 6 and 12 months. Predictive models were created using backward stepwise logistic and linear multivariate regression analyses. Results: Several predictors were present including age, expectancy of improvement, global perceived effect; however, we only identified baseline disability as a universal predictor of outcomes at 6 months. The second most represented universal predictor was baseline pain intensity for outcomes at 12 months. Discussion: Only two predictors demonstrated an association with more than one outcome measure. High baseline disability predicts multidimensional outcome measures at 6 months in patients with chronic LBP while baseline pain intensity can best predict the outcome at 12 months. Nevertheless, other predictors seem to be unique to the outcome used. Level of evidence: 2c.
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Affiliation(s)
- Alessandra Narciso Garcia
- a Doctor of Physical Therapy Division, Department of Orthopaedic Surgery, Duke University , Durham , NC , USA
| | - Leonardo O P Costa
- b Physical Therapy, University Cidade de Sao Paulo , Sao Paulo , Brazil.,c School of Public Health, Sydney Medical School, The University of Sydney, Ashleigh Provest , Sydney , Australia
| | | | - Mark Hancock
- e Discipline of Physiotherapy, Faculty of Human Sciences, Macquarie University , Sydney , Australia
| | - Chad Cook
- f Doctor of Physical Therapy Division, Duke Clinical Research Institute, Duke University , Durham , NC , USA
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Karstens S, Krug K, Raspe H, Wunderlich M, Hochheim M, Joos S, Hüppe A. Prognostic ability of the German version of the STarT Back tool: analysis of 12-month follow-up data from a randomized controlled trial. BMC Musculoskelet Disord 2019; 20:94. [PMID: 30819162 PMCID: PMC6393968 DOI: 10.1186/s12891-019-2467-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 02/13/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Stratified care is an up-to-date treatment approach suggested for patients with back pain in several guidelines. A comprehensively studied stratification instrument is the STarT Back Tool (SBT). It was developed to stratify patients with back pain into three subgroups, according to their risk of persistent disabling symptoms. The primary aim was to analyse the disability differences in patients with back pain 12 months after inclusion according to the subgroups determined at baseline using the German version of the SBT (STarT-G). Moreover, the potential to improve prognosis for disability by adding further predictor variables, an analysis for differences in pain intensity according to the STarT-Classification, and discriminative ability were investigated. METHODS Data from the control group of a randomized controlled trial were analysed. Trial participants were members of a private medical insurance with a minimum age of 18 and indicated as having persistent back pain. Measurements were made for the risk of back pain chronification using the STarT-G, disability (as primary outcome) and back pain intensity with the Chronic Pain Grade Scale (CPGS), health-related quality of life with the SF-12, psychological distress with the Patient Health Questionnaire-4 (PHQ-4) and physical activity. Analysis of variance (ANOVA), multiple linear regression, and area under the curve (AUC) analysis were conducted. RESULTS The mean age of the 294 participants was 53.5 (SD 8.7) years, and 38% were female. The ANOVA for disability and pain showed significant differences (p < 0.01) among the risk groups at 12 months. Post hoc Tukey tests revealed significant differences among all three risk groups for every comparison for both outcomes. AUC for STarT-G's ability to discriminate reference standard 'cases' for chronic pain status at 12 months was 0.79. A prognostic model including the STarT-Classification, the variables global health, and disability at baseline explained 45% of the variance in disability at 12 months. CONCLUSIONS Disability differences in patients with back pain after a period of 12 months are in accordance with the subgroups determined using the STarT-G at baseline. Results should be confirmed in a study developed with the primary aim to investigate those differences.
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Affiliation(s)
- Sven Karstens
- Department of Computer Science, Therapeutic Sciences, Trier University of applied Science, Trier, Germany. .,Department of General Practice, University of Tuebingen, Tuebingen, Germany.
| | - Katja Krug
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Heiner Raspe
- Institute of Social Medicine and Epidemiology, University of Luebeck, Luebeck, Germany
| | - Max Wunderlich
- Central Krankenversicherung AG, Cologne, Germany.,Generali Health Solutions GmbH, Cologne, Germany
| | - Martin Hochheim
- Central Krankenversicherung AG, Cologne, Germany.,Generali Health Solutions GmbH, Cologne, Germany
| | - Stefanie Joos
- Department of General Practice, University of Tuebingen, Tuebingen, Germany
| | - Angelika Hüppe
- Institute of Social Medicine and Epidemiology, University of Luebeck, Luebeck, Germany
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Tackling low back pain in Brazil: a wake-up call. Braz J Phys Ther 2018; 23:189-195. [PMID: 30337255 DOI: 10.1016/j.bjpt.2018.10.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/28/2018] [Accepted: 10/03/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Low back pain is the leading cause of years lived with disability in Brazil based upon Global Burden of Disease estimates. Since 1990, the number of years lived with disability has increased by 79.7%, and this number is expected to continue to rise due to population growth and ageing. Yet, similarly to other countries, little attention has been given to it in both the public and private health systems, arguably making it an overlooked epidemic in Brazil. There is evidence that Brazil has adopted unwarranted practices in the management of low back pain in a similar manner to what has been observed in high-income countries. To tackle the burden of low back pain in Brazil, we need highly coordinated efforts from government, the private sector, universities, health workers and civil society. OBJECTIVE This masterclass intends to provide an overview of the challenges faced by Brazil in relation to low back pain management and propose potential solutions that could potentially be implemented based on experiences reported in the literature.
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Werneke MW, Edmond S, Young M, Grigsby D, McClenahan B, McGill T. Association between changes in function among patients with lumbar impairments classified according to the STarT Back Screening Tool and managed by McKenzie credentialed physiotherapists. Physiother Theory Pract 2018; 36:589-597. [DOI: 10.1080/09593985.2018.1490839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
| | - Susan Edmond
- Doctoral Programs in Physical Therapy, Rutgers The State University of New Jersey, Newark, NJ, USA
| | - Michelle Young
- Rehabilitation Services, Valley Health Wellness and Fitness Center, Winchester, VA, USA
| | - David Grigsby
- MidSouth Orthopaedic Rehabilitation, Physical Therapy, Cordova, TN, USA
| | | | - Troy McGill
- Providence Rehabilitation Services, Outpatient Therapies, Providence Alaska Medical Center, Anchorage, AK, USA
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Sowden G, Hill JC, Morso L, Louw Q, Foster NE. Advancing practice for back pain through stratified care (STarT Back). Braz J Phys Ther 2018; 22:255-264. [PMID: 29970301 PMCID: PMC6095099 DOI: 10.1016/j.bjpt.2018.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/07/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Low back pain (LBP) is common, however research comparing the effectiveness of different treatments over the last two decades conclude either no or small differences in the average effects of different treatments. One suggestion to explain this is that patients are not all the same and important subgroups exist that might require different treatment approaches. Stratified care for LBP involves identifying subgroups of patients and then delivering appropriate matched treatments. Research has shown that stratified care for LBP in primary care can improve clinical outcomes, reduce costs and increase the efficiency of health-care delivery in the UK. The challenge now is to replicate and evaluate this approach in other countries health care systems and to support services to implement it in routine clinical care. RESULTS The STarT Back approach to stratified care has been tested in the National Health Service, within the UK, it reduces unnecessary overtreatment in patients who have a good prognosis (those at low risk) yet increases the likelihood of appropriate healthcare and associated improved outcomes for those who are at risk of persistent disabling pain. The approach is cost-effective in the UK healthcare setting and has been recommended in recent guidelines and implemented as part of new LBP clinical pathways of care. This approach has subsequently generated international interest, a replication study is currently underway in Denmark, however, some lessons have already been learnt. There are potential obstacles to implementing stratified care in low-and-middle-income settings and in other high-income settings outside of the UK, however, implementation science literature can inform the development of innovations and efforts to support implementation of stratified care. CONCLUSIONS The STarT Back approach to stratified care for LBP is a promising method to advance practice that has demonstrated clinical and cost effectiveness in the UK. Over time, further evidence for both the effectiveness and the adaptations needed to test and implement the STarT Back stratified care approach in other countries is needed.
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Affiliation(s)
- Gail Sowden
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK; Interdisciplinary Musculoskeletal Pain Assessment and Community Treatment Service, Haywood Hospital, High Lane, Burslem, Stoke-On-Trent ST6 7AG, UK.
| | - Jonathan Charles Hill
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Lars Morso
- Centre for Quality, Department of Regional Health Research, University of Southern Denmark, Winsloewparken 19, 3 Odense C DK 5000, Denmark
| | - Quninette Louw
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Nadine Elizabeth Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
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Beneciuk JM, Lentz TA, He Y, Wu SS, George SZ. Prediction of Persistent Musculoskeletal Pain at 12 Months: A Secondary Analysis of the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Validation Cohort Study. Phys Ther 2018; 98:290-301. [PMID: 29669081 PMCID: PMC6256953 DOI: 10.1093/ptj/pzy021] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 02/06/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Musculoskeletal pain is a societal epidemic because it is highly prevalent and a leading contributor to disability; however, physical therapists are still challenged when predicting which patients are at high risk for persistent symptoms. OBJECTIVE The objectives of this study were to identify patient characteristics predictive of persistent musculoskeletal pain 12 months following physical therapist care and to determine the influence of anatomical region. DESIGN The design included a secondary analysis of a cohort study. METHODS Participants ranged in age from 18 to 65 years, had a primary report of knee, shoulder, back, or neck pain, were receiving physical therapy, and were enrolled in the Orthopedic Physical Therapy Investigative Network (OPT-IN) Optimal Screening for Prediction of Referral and Outcome (OSPRO) validation cohort study. Candidate predictor variables included demographic and clinical characteristics, comorbidities, and OSPRO Review of Systems (OSPRO-ROS) and OSPRO Yellow Flag (OSPRO-YF) tool scores. Persistent musculoskeletal pain was assessed by self-report responses to questions on the duration of pain and activity limitation. Logistic regression was used for completed cases to identify predictors of persistent pain at 12 months in full and parsimonious models. RESULTS Follow-up assessment at 12 months was performed for 63.4% of participants (279/440). Participants with persistent pain at 12 months (n = 101; 36.2%) had more comorbidities, higher numerical pain rating scale scores, and higher OSPRO-ROS and OSPRO-YF tool scores at baseline than those without persistent pain, and the findings were independent of anatomical region. The number of comorbidities (odds ratio [OR] range = 0.30-0.46), numerical pain rating scale scores (OR at baseline = 1.44-1.75; OR at 4 weeks = 1.37-1.39), and OSPRO-ROS (plus additional items) scores (OR = 1.33-1.54) were predictors in full and parsimonious models. LIMITATIONS Convenience sampling was used, with a follow-up rate at 12 months (63.4%) that was lower than anticipated, and an operational definition for chronic low back pain was applied to persistent musculoskeletal pain in other body regions. CONCLUSIONS The OSPRO-ROS tool may be used to improve the prediction of persistent musculoskeletal pain at 12 months in conjunction with comorbidities and pain intensity (baseline and 4 weeks). These are potentially important findings because persistent pain was not commonly evaluated in previous screening studies; however, it is a relevant outcome in an era of front-line nonpharmacological pain management.
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Affiliation(s)
- Jason M Beneciuk
- Department of Physical Therapy, University of Florida, Gainesville, Florida, and Brooks Rehabilitation Clinical Research Center, 3901 University Blvd S, Ste 103, Jacksonville, FL 32216 (USA),Address all correspondence to Dr Beneciuk at:
| | - Trevor A Lentz
- Duke Clinical Research Institute, Durham, North Carolina
| | - Ying He
- Department of Mathematics, Clarkson University, Potsdam, New York
| | - Samuel S Wu
- Department of Biostatistics, University of Florida, Gainesville, Florida
| | - Steven Z George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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Medeiros FC, Costa LOP, Oliveira IS, Oshima RK, Costa LCM. The use of STarT BACK Screening Tool in emergency departments for patients with acute low back pain: a prospective inception cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2823-2830. [PMID: 29671109 DOI: 10.1007/s00586-018-5586-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 01/30/2018] [Accepted: 04/04/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE (1) To analyse the clinical utility of the STarT Back Screening Tool (SBST) in emergency departments by describing changes in classification over time and; (2) to identify what would be the best time to use the SBST to predict long-term clinical outcomes in patients with acute nonspecific low back pain (LBP) seeking emergency care. METHODS A 6 months prospective inception cohort study was conducted. 200 participants with LBP seeking emergency medical treatment were included. Pain intensity, disability and SBST were collected at baseline, 6 and 26 weeks. Categories of improvement, clinical worsening, and stability were created to calculate the changes in the SBST subgroups. Linear regression models were built to analyse the predictive ability of SBST when applied at baseline, 6 weeks as well as changes in the subgroup from baseline to 6 weeks. These models were adjusted for potential confounders. RESULTS 45% of patients were classified as high risk of chronicity at baseline. Most patients classified as medium (86.7%) or high (52.4%) risk changed their risk subgroup after 6 weeks and most of them improved. The SBST improved the prediction for all outcomes when applied at 6 weeks (R2 = 22.1% for disability and R2 = 15.6% for pain intensity), but not at baseline. CONCLUSION Most of patients seeking care in emergency departments with a new episode of acute LBP improved after 6 weeks. The use of SBST to guide initial treatment and to predict clinical outcomes are most indicated when the instrument is applied after 6 weeks after presentation to emergency care. These slides can be retrieved under Electronic Supplementary material.
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Affiliation(s)
- Flávia Cordeiro Medeiros
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Rua Cesário Galeno 448, Tatuapé, SP, 03071-100, Brazil.
| | - Leonardo Oliveira Pena Costa
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Rua Cesário Galeno 448, Tatuapé, SP, 03071-100, Brazil
| | - Indiara Soares Oliveira
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Rua Cesário Galeno 448, Tatuapé, SP, 03071-100, Brazil
| | - Renan Kendy Oshima
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Rua Cesário Galeno 448, Tatuapé, SP, 03071-100, Brazil
| | - Lucíola Cunha Menezes Costa
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Rua Cesário Galeno 448, Tatuapé, SP, 03071-100, Brazil
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Tomazoni SS, Costa LDCM, Guimarães LDS, Araujo AC, Nascimento DP, Medeiros FCD, Avanzi MA, Costa LOP. Effects of photobiomodulation therapy in patients with chronic non-specific low back pain: protocol for a randomised placebo-controlled trial. BMJ Open 2017; 7:e017202. [PMID: 29070637 PMCID: PMC5665327 DOI: 10.1136/bmjopen-2017-017202] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/04/2017] [Accepted: 08/17/2017] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Low back pain (LBP) is one of the largest and most frequent public health problems worldwide. Photobiomodulation therapy (PBMT) is a frequently used non-pharmacological therapy for the treatment of musculoskeletal disorders. However, there is little high-quality scientific evidence that demonstrates the effectiveness of PBMT in the treatment of patients with chronic LBP in the short, medium and long term. Therefore, the objective of this clinical trial is to evaluate the effects of PBMT in patients with chronic non-specific LBP in the short, medium and long term. METHODS AND ANALYSES This is a prospectively registered, two-arm randomised placebo-controlled trial with blinded patients, assessors and treatment providers. One hundred and forty-eight patients with chronic non-specific LBP will be recruited. Treatment sessions will be provided three times a week for 4 weeks (totaling 12 sessions) with patients receiving either placebo or active PBMT. For ethical reasons, all patients, regardless of treatment allocation, will also receive an information booklet based on 'The Back Book'. Clinical outcomes will be measured at baseline, at the end of treatment, as well as 3, 6 and 12 months after randomisation. The primary outcomes will be pain intensity and disability measured after 12 sessions of treatment. The secondary outcomes will be pain intensity and disability measured at 3, 6 and 12 months after randomisation, in addition to specific disability and global perceived effect in all time points. ETHICS AND DISSEMINATION The study was approved by the Research Ethics Committee of Universidade Cidade de São Paulo. The results will be disseminated through scientific publications and presentations at national and international scientific meetings. TRIAL REGISTRATION NUMBER NCT03089424.
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Affiliation(s)
- Shaiane Silva Tomazoni
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Brazil
| | | | | | - Amanda Costa Araujo
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Brazil
| | - Dafne Port Nascimento
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Brazil
| | | | - Marina Athayde Avanzi
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Brazil
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