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Raghava Neelapala YV, Sharma S, Carlesso L. Exploring the association of gender role expectations of pain and measures of pain sensitization in people with knee osteoarthritis: A cross-sectional study. Osteoarthritis Cartilage 2024:S1063-4584(24)01133-6. [PMID: 38574800 DOI: 10.1016/j.joca.2024.03.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 02/26/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVES First, we explored the association between Gender Role Expectations of Pain (GREP), and psychophysical measures of sensitization in people with knee osteoarthritis (OA). Second, we explored whether the association differed by level of GREP items (high vs low scores). DESIGN We conducted secondary analyses of a cohort study. Those who were (i) age of ≥40, English or French speaking, ii) diagnosed with knee OA using American College of Rheumatology criteria and iii) consulting with an orthopedic surgeon were included. GREP items pertaining to pain sensitivity and pain endurance of the typical man or woman were rated by males and females respectively. Psychophysical tests consisted of pressure pain thresholds (PPTs), Temporal Summation (TS), and Conditioned Pain Modulation (CPM). Multiple linear regression models for males and females were run with GREP scores (independent variables) and psychophysical tests (dependent variables). Next models stratified on the median split of GREP scores were run. Models were adjusted for age, BMI, pain catastrophizing, anxio-depressive symptoms, and radiographic severity. RESULTS 280 participants (57% females; age (SD): 63.9 (9.6) and BMI (SD): 31.3 (8.40)) were included. GREP pain sensitivity scores in males were associated with CPM values (β: 95% CI: 0.09 (0.01 to 0.17)). Males with low GREP pain sensitivity or pain endurance had very small to small positive associations with PPT and CPM values. CONCLUSION This first exploration of gendered pain sensitivity and pain endurance by males and females has small and clinically unimportant associations with measures of pain sensitization requiring further validation.
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Affiliation(s)
| | - Saurab Sharma
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales; and Centre for Pain IMPACT, Neuroscience Research, Australia
| | - Lisa Carlesso
- School of Rehabilitation Sciences, McMaster University, Hamilton, Canada.
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Aoyagi K, Jafarzadeh SR, Carlesso L, Law LF, Lewis CE, Nevitt M, Neogi T. Mediating Effect of Pain Sensitization on the Paradoxical Relation of Taking Opioids to Pain Severity in Knee Osteoarthritis: The Multicenter Osteoarthritis Study. Arthritis Care Res (Hoboken) 2024; 76:403-408. [PMID: 37750238 PMCID: PMC10922135 DOI: 10.1002/acr.25244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/16/2023] [Accepted: 11/21/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE One of the less understood adverse effects while taking opioids is the paradoxical increase in pain, known as opioid-induced hyperalgesia (OIH). We sought to determine whether pain sensitization mediates the relation of taking an opioid to pain severity in people with knee osteoarthritis (OA). METHODS We included participants in a National Institutes of Health-funded cohort study of people with or at risk of knee OA. Participants were categorized into opioid and nonopioid analgesic groups at baseline. Western Ontario McMaster Universities OA Index (WOMAC) pain two years later was assessed as the outcome. We used causal mediation analysis to assess the mediating role of pain sensitization, quantified by changes in pressure pain threshold (PPT) at the wrist and patella over two years, on the effect of taking an opioid on WOMAC pain two years later. RESULTS We included 296 participants who took opioids and 1,070 participants who took nonopioid analgesics. Compared with taking nonopioid analgesics, taking opioids was associated with greater pain two years later. This relation was mediated by 0.05- and 0.08-unit changes in wrist PPT (95% confidence interval [CI] 0.01-0.10) and patellar PPT (95% CI 0.02-0.14), respectively. When we assessed any worsening in WOMAC pain score over two years, taking opioids, compared with taking nonopioid analgesics, had 2% and 5% higher odds of experiencing any worsening pain mediated by changes in wrist PPT (95% CI 0.99-1.04) and patellar PPT (95% CI 1.01-1.09), respectively. CONCLUSION Pain sensitization had small mediating effects on the paradoxical phenomenon of OIH, suggesting that pain sensitization may not play a major role and/or that PPT is an inadequate tool to assess OIH.
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Affiliation(s)
- Kosaku Aoyagi
- University of Texas at El Paso, El Paso, TX, USA
- Boston University School of Medicine, Boston, MA, USA
| | | | | | | | | | - Michael Nevitt
- University of California San Francisco, San Francisco, CA, USA
| | - Tuhina Neogi
- Boston University School of Medicine, Boston, MA, USA
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Madden K, Pallapothu S, Young Shing D, Adili A, Bhandari M, Carlesso L, Khan M, Kleinlugtenbelt YV, Krsmanovic A, Nowakowski M, Packham T, Romeril E, Tarride JE, Thabane L, Tushinski DM, Wallace C, Winemaker M, Shanthanna H. Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty. Pilot Feasibility Stud 2024; 10:30. [PMID: 38360686 PMCID: PMC10868001 DOI: 10.1186/s40814-024-01457-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA. METHODS This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use. DISCUSSION The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making. TRIAL REGISTRATION Prospectively registered in Clinicaltrials.gov (NCT04968132).
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Affiliation(s)
- Kim Madden
- Department of Surgery, McMaster University, Hamilton, Canada.
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada.
- Department of Health Research Methods, McMaster University, Hamilton, Canada.
| | | | | | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Lisa Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Moin Khan
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Adrijana Krsmanovic
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Matilda Nowakowski
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Tara Packham
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Eric Romeril
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Jean-Eric Tarride
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
- Center for Health Economics and Policy Analyses, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, McMaster University, Hamilton, Canada
| | - Daniel M Tushinski
- Department of Surgery, McMaster University, Hamilton, Canada
- Hamilton Health Sciences-Juravinski Hospital, Hamilton, Canada
| | - Christine Wallace
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
| | | | - Harsha Shanthanna
- Department of Surgery, McMaster University, Hamilton, Canada
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Canada
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Straatman LN, Lukacs MJ, Carlesso L, Grewal R, Lalone EA, Walton DM. A systematic review of the psychometric properties of pressure pain detection threshold in evaluating mechanical pain threshold in people with hand or wrist injuries. J Hand Ther 2023; 36:845-859. [PMID: 37778878 DOI: 10.1016/j.jht.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/16/2022] [Accepted: 06/09/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE The aim of this study was to conduct a systematic review of the psychometric properties of Pressure Pain Detection Threshold (PPDT) measures in people with hand or wrist injuries. STUDY DESIGN AND METHODS MEDLINE, Embase, and CINAHL databases were searched to identify eligible studies evaluating psychometric properties of PPDT in samples composed of at least 50% of people with hand or wrist injury. The Consensus-based Standards for the Measurement of Health Instruments' risk of bias checklist was used to critically appraise the included studies, and qualitative synthesis was performed by pooling the results of all studies that presented the same measurement property using Grading of Recommendations, Assessment, Development, and Evaluation. RESULTS From 415 studies, 11 relevant studies were identified. Of the 11 studies, four hand or wrist injuries were represented; carpal tunnel syndrome, distal radius fractures, osteoarthritis, and complex regional pain syndrome. Intra-rater reliability was considered sufficient (intraclass correlation coefficient 0.64-0.94), with small reported standard error of the mean values (5.3-39.2 kPa). Results of validity and responsiveness could not be synthesized due to heterogeneity. Risk of bias for reliability and measurement error was assessed as very good or adequate, whereas validity and responsiveness were doubtful or inadequate. Overall quality of evidence was low or very low for all measurement properties. CONCLUSIONS Inconsistent results and low quality evidence provide little confidence in the overall measurement properties of PPDT in a hand or wrist injury population. No criterion standard for pain further highlights complexities around pain measurement such that the results obtained from PPDT measures in clinical practice cannot be compared to a gold standard measure.
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Affiliation(s)
- Lauren N Straatman
- Department of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada; Bone and Joint Institute, Western University, London, Ontario, Canada.
| | - Michael J Lukacs
- School of Physical Therapy, Western University, London, Ontario, Canada; Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Lisa Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Ruby Grewal
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Emily A Lalone
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada; Bone and Joint Institute, Western University, London, Ontario, Canada
| | - David M Walton
- Department of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada; School of Physical Therapy, Western University, London, Ontario, Canada; Bone and Joint Institute, Western University, London, Ontario, Canada
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Neelapala YVR, Mercuri D, Macedo L, Hanna S, Kobsar D, Carlesso L. Mechanisms hypothesized for pain-relieving effects of exercise in fibromyalgia: a scoping review. Ther Adv Musculoskelet Dis 2023; 15:1759720X231182894. [PMID: 37484924 PMCID: PMC10356998 DOI: 10.1177/1759720x231182894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023] Open
Abstract
Background Exercise is one of the most recommended management strategies by treatment guidelines for fibromyalgia (FM); however, the mechanism through which exercise improves pain in FM is still unknown. Objective We aimed to summarize the hypothesized theoretical mechanisms for the pain-relieving effects of exercise in people with FM. Eligibility Criteria Randomized controlled trials (RCTs) in English reporting mechanisms for pain-relieving effects of exercise in the 'Introduction' and 'Discussion' sections and significant within- group or between-group effects of exercise interventions were included. Sources of Evidence We searched the databases Ovid MEDLINE(R), EMBASE, CINAHL, COCHRANE, Sports Discuss, and AMED with the keywords: exercise and fibromyalgia until December 2021. Charting Methods Two authors independently performed title/abstract, full-text review, and data abstraction using a data abstraction form. The hypothesized mechanisms from individual studies were grouped into three categories. Results The literature search resulted in 2147 studies, out of which 220 studies were considered for full-text review. A total of 50 RCTs proposing 29 unique mechanisms for the pain-relieving effects of exercise were included. These mechanisms were divided into three categories: physical, neuro-physiological, and psychological. The neuro-physiological category was further subdivided into exercise-induced hypoalgesia (EIH), pain sensitization, the autonomic system, the immune system, the endocrine system, and miscellaneous categories. The most frequently hypothesized mechanisms were EIH (n = 15), autonomic modulation (n = 7), improved sleep (n = 6), muscle oxygenation (n = 6), self-efficacy (n = 5), mental health (n = 4), and benefits of the aquatic environment (n = 12). While all exercise interventions involved FM patients, most of the supporting evidence for these mechanisms was cited from previous studies conducted on healthy samples. No studies performed analyses to demonstrate causal associations between the mechanisms and outcomes. Conclusion Multiple mechanisms were hypothesized for the positive influence of exercise in people with FM. Future studies using causal analyses, such as mediation analysis, are recommended to validate these mechanisms.
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Affiliation(s)
| | - Domenico Mercuri
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Luciana Macedo
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Steven Hanna
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dylan Kobsar
- Department of Kinesiology, McMaster University, Hamilton, ON, Canada
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Aoyagi K, Law LF, Carlesso L, Nevitt M, Lewis CE, Wang N, Neogi T. Post-surgical contributors to persistent knee pain following knee replacement: The Multicenter Osteoarthritis Study (MOST). Osteoarthr Cartil Open 2023; 5:100335. [PMID: 36798734 PMCID: PMC9926203 DOI: 10.1016/j.ocarto.2023.100335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/06/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
Objective Pain persistence following knee replacement (KR) occurs in ∼20-30% of patients. Although several studies have identified preoperative risk factors for persistent post-KR pain, few have focused on post-KR contributing factors. We sought to determine whether altered nociceptive signaling and other peripheral nociceptive drivers present post-operatively contribute to post-KR pain. Design We included participants from the Multicenter Osteoarthritis Study who were evaluated ∼12 months after KR. We evaluated the relation of measures of pain sensitivity [pressure pain threshold (PPT), temporal summation (TS), and conditioned pain modulation (CPM)] and the number of painful body sites to post-KR WOMAC knee pain, and of the number of painful sites to altered nociceptive signaling using linear or logistic regression models, as appropriate. Results 171 participants (mean age 69 years, 62% female) were included. TS was associated with worse WOMAC pain post-KR (β = 0.77 95% CI:0.19-1.35) and reduced odds of achieving patient acceptable symptom state (aOR = 0.54 95%CI:0.34-0.88). Inefficient CPM was also associated with worse WOMAC pain post-KR (β = 1.43 95% CI:0.15-2.71). In contrast, PPT was not associated with these outcomes. The number of painful body sites present post-KR was associated with TS (β = 0.05, 95% CI:0.01, 0.05). Conclusions Post-KR presence of central sensitization and inefficient descending pain modulation was associated with post-KR pain. We also noted that presence of other painful body sites contributes to altered nociceptive signaling, and this may thus also contribute to the experience of knee pain post-KR. Our findings provide novel insights into central pain mechanisms and other peripheral pain sources contributing to post-KR persistent knee pain.
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Affiliation(s)
- Kosaku Aoyagi
- Section of Rheumatology, Boston University School of Medicine, Boston, MA, USA
- Department of Rehabilitation Sciences, University of Texas at El Paso, El Paso, TX, USA
| | | | | | - Michael Nevitt
- University of California San Francisco, San Francisco, CA, USA
| | | | - Na Wang
- Boston University School of Public Health, Boston, MA, USA
| | - Tuhina Neogi
- Section of Rheumatology, Boston University School of Medicine, Boston, MA, USA
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Southerst D, Bakaa N, Côté P, Macedo L, Carlesso L, MacDermid J, Mior S. Diversity of the chiropractic profession in Canada: a cross-sectional survey of Canadian Chiropractic Association members. Chiropr Man Therap 2022; 30:52. [PMID: 36494690 PMCID: PMC9733254 DOI: 10.1186/s12998-022-00463-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Little is known about the diversity of the chiropractic profession with respect to gender, sexual orientation, race, ethnicity and community of practice. This knowledge is important as profession representation of key equity seeking groups may impact quality of care and access for vulnerable communities. The aim of this cross-sectional survey was to explore the diversity of the chiropractic profession in Canada. METHODS All registered members of the Canadian Chiropractic Association (N = 7721) were invited to participate in a web-based survey between May and June 2021. Survey questions explored diversity with respect to personal demographics (age, sex, gender, sexual orientation, race, ethnicity, language) and practice characteristics (community setting, practice type). Where possible, survey data was compared to data from the 2016 Census of the Canadian population. RESULTS We received a total of 3143 survey responses (response rate-41%). The average age of our sample was 44.7 years (standard deviation 12.7). Forty-five percent were female with the same proportion (45.2%) self-identifying as women. Ninety-one percent of the sample self-identified as heterosexual. With respect to race, 80% of respondents were Caucasian. Seventy percent of chiropractors in our sample identified with Canadian ancestry and 29% with European ancestry. In comparison to the Canadian population, some visible minorities were underrepresented. The greatest discrepancy between the Canadian population and our sample was in the proportion of Black and Indigenous chiropractors. With respect to ethnicity, chiropractors identifying themselves with Canadian ancestry were overrepresented in our sample compared to others, specifically those with North American Indigenous and South, Central and Latin American ancestry. Sixty-one percent of chiropractors practiced in major cities and most work in interdisciplinary clinics (42% Complementary and Alternative Medicine and 33% rehabilitation). CONCLUSIONS This study provides an initial description of diversity within the chiropractic profession in Canada. Women represent less than 50% of the profession nationally. Overall, there is little racial and ethnic diversity in the chiropractic profession compared to the Canadian population, with Black and Indigenous peoples being underrepresented. Future work should focus strategies to foster the development of a more diverse chiropractic workforce.
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Affiliation(s)
- Danielle Southerst
- grid.266904.f0000 0000 8591 5963Institute for Disability and Rehabilitation Research, Ontario Tech University, Oshawa, Canada
| | - Nora Bakaa
- grid.25073.330000 0004 1936 8227School of Rehabilitation Sciences, McMaster University, Hamilton, Canada
| | - Pierre Côté
- grid.266904.f0000 0000 8591 5963Institute for Disability and Rehabilitation Research, Ontario Tech University, Oshawa, Canada
| | - Luciana Macedo
- grid.25073.330000 0004 1936 8227School of Rehabilitation Sciences, McMaster University, Hamilton, Canada
| | - Lisa Carlesso
- grid.25073.330000 0004 1936 8227School of Rehabilitation Sciences, McMaster University, Hamilton, Canada
| | - Joy MacDermid
- grid.39381.300000 0004 1936 8884School of Physical Therapy, Western University, London, Canada
| | - Silvano Mior
- Institute for Disability and Rehabilitation Research, Ontario Tech University, Oshawa, Canada. .,Division of Research, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada.
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Wideman TH, Bostick G, Miller J, Thomas A, Bussières A, Walton D, Tousignant-Laflamme Y, Carlesso L, Hunter J, Perreault K, Shay B. The development of a stakeholder-endorsed national strategic plan for advancing pain education across Canadian physiotherapy programs. Can J Pain 2022; 6:21-32. [PMID: 35694143 PMCID: PMC9176229 DOI: 10.1080/24740527.2022.2056006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The Canadian Pain Task Force recently advanced an action plan calling for improved entry-level health professional pain education. However, there is little research to inform the collaboration and coordination across stakeholders that is needed for its implementation. Aims This article reports on the development of a stakeholder-generated strategic plan to improve pain education across all Canadian physiotherapy (PT) programs. Methods Participants included representatives from the following stakeholder groups: people living with pain (n = 1), PT students and recent graduates (n = 2), educators and directors from every Canadian PT program (n = 24), and leaders of Canada's national PT professional association (n = 2). Strategic priorities were developed through three steps: (1) stakeholder-generated data were collected and analyzed, (2) a draft strategic plan was developed and refined, and (3) stakeholder endorsement of the final plan was assessed. The project was primarily implemented online between 2016 and 2018. Results The plan was developed through five iterative versions. Stakeholders unanimously endorsed a plan that included five priorities focusing on uptake of best evidence across (1) national PT governance groups and (2) within individual PT programs; (3) partnering with people living with pain in pain education; (4) advocacy for the PT role in pain management; and (5) advancing pain education research. Conclusion This plan is expected to help Canadian stakeholders work toward national improvements in PT pain education and to serve as a useful template for informing collaboration on entry-level pain education within other professions and across different geographic regions.
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Affiliation(s)
- Timothy H. Wideman
- School of Physical and Occupational Therapy McGill University, Montreal, Quebec, Canada,CONTACT Timothy H. Wideman School of Physical and Occupational Therapy Faculty of Medicine, McGill University, Hosmer House, Room 303B, 3630 Promenade Sir-William-Osler, Montreal, QCH3G 1Y5, Canada
| | - Geoffrey Bostick
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Jordan Miller
- School of Rehabilitation Therapy, Queen’s University, Kingston, Canada
| | - Aliki Thomas
- School of Physical and Occupational Therapy McGill University, Montreal, Quebec, Canada,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal
| | - André Bussières
- School of Physical and Occupational Therapy McGill University, Montreal, Quebec, Canada
| | - David Walton
- School of Physical Therapy, Western University, London, Ontario, Canada
| | | | - Lisa Carlesso
- School of Rehabilitation Science, Faculty of Health Sciences, McMaster UniversityHamilton, Ontario, Canada
| | - Judith Hunter
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Kadija Perreault
- Department of Rehabilitation Science, Faculty of Medicine, Université Laval, Québec City, Canada
| | - Barbara Shay
- Department of Physical Therapy, University of Manitoba, Winnipeg, Manitoba, Canada
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Aoyagi K, Liew JW, Farrar JT, Wang N, Carlesso L, Kumar D, Frey Law L, Lewis CE, Nevitt M, Neogi T. Does weight-bearing versus non-weight-bearing pain reflect different pain mechanisms in knee osteoarthritis?: the Multicenter Osteoarthritis Study (MOST). Osteoarthritis Cartilage 2022; 30:545-550. [PMID: 34801670 PMCID: PMC8940656 DOI: 10.1016/j.joca.2021.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/05/2021] [Accepted: 10/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Knee osteoarthritis (OA) is predominantly characterized by pain with weight-bearing activities. Pain at rest also occurs but the mechanisms for this are not clear. We evaluated the relations of nociceptive signal alterations to weight-bearing and non-weight-bearing pain in knee OA. DESIGN We used data from a NIH-funded longitudinal cohort of older adults with or at risk of knee OA. We evaluated quantitative sensory testing (QST) measures (pressure pain threshold (PPT) at patellae and the wrist; mechanical temporal summation (TS); conditioned pain modulation (CPM)). Each WOMAC pain question was dichotomized as having at least moderate pain, and we further categorized them as weight-bearing pain and non-weight-bearing pain. We evaluated the relation of QST measures to each pain outcome using logistic regression, adjusting for potential confounders. RESULTS 2,749 participants (5,479 knees) were included (mean age 64 ± 11, 57% female). Each SD unit decrease in patellar PPT was associated with greater odds of both weight-bearing pain (OR 1.51 (95% CI 1.27, 1.79)) and non-weight-bearing pain (OR 1.46 (1.20-1.77)), while wrist PPT was associated with greater odds of weight-bearing pain (OR 1.27 (1.15, 1.39)) but only with pain during sitting/lying (OR 1.20 (1.01, 1.43)). TS was significantly associated with greater odds of pain with walking and stairs (OR 1.11 (1.01, 1.23), 1.11 (1.03, 1.20), respectively). CPM was not associated with any pain outcomes. CONCLUSIONS Our findings challenge the hypothesis that non-weight-bearing pain may reflect greater pain sensitization and/or inefficient CPM than weight-bearing pain in knee OA, suggesting other mechanisms are likely responsible.
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Affiliation(s)
- K Aoyagi
- Boston University School of Medicine, Boston, MA, USA.
| | - J W Liew
- Boston University School of Medicine, Boston, MA, USA.
| | - J T Farrar
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - N Wang
- Boston University School of Public Health, Boston, MA, USA.
| | | | - D Kumar
- Boston University School of Medicine, Boston, MA, USA.
| | | | - C E Lewis
- University of Alabama, Birmingham, AL, USA.
| | - M Nevitt
- University of California San Francisco, San Francisco, CA, USA.
| | - T Neogi
- Boston University School of Medicine, Boston, MA, USA.
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10
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Bakaa N, Chen LH, Carlesso L, Richardson J, Shanthanna H, Macedo L. Understanding barriers and facilitators of exercise adherence after total-knee arthroplasty. Disabil Rehabil 2021; 44:6348-6355. [PMID: 34397309 DOI: 10.1080/09638288.2021.1965232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this qualitative study is to understand the perceived patient barriers and facilitators of post-surgical exercise adherence in patients undergoing TKA. MATERIAL AND METHODS We used an interpretive description approach. Data was gathered using semi-structured qualitative interviews. Participants were interviewed at 8 weeks post-operatively to capture physical, psychological, social and contextual changes and information. Topics that were explored included participants' experience with physical activity and exercise, motivation to perform physical activity, beliefs that exercise will reduce pain, factors that limit their ability to engage in exercise, and the importance of self-regulation in exercise adherence. RESULTS This study identified 4 themes within the WHO adherence framework: patient-related factors, condition-related factors, health care system, and social support. In particular, self-regulation, knowledge of exercise, post-operative complications, comorbidities, social support, and lack of guidance from health care providers were identified as personal and environmental characteristics that influence exercise adherence. CONCLUSION Exercise adherence is a multidimensional, interconnected construct and future research should focus on understanding the factors, particularly health care system, that impact adherence.IMPLICATIONS FOR REHABILITATIONRehabilitation therapists should aim to foster competence and confidence in post-operative rehabilitation by implementing strategies such as positive-reinforcement, goal setting, and increased education regarding the benefits of exercise.Clinical strategies to improve exercise adherence should be implemented both pre-and-post-operatively.Health care providers should clearly discuss post-operative outcomes and expectations (e.g., complications, etc.) with patients prior to surgery.
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Affiliation(s)
- Nora Bakaa
- School of Rehabilitation Sciences, Faculty of Health Sciences, Institute of Applied Health Sciences, McMaster University, Hamilton, Canada
| | - Lu Hsi Chen
- School of Rehabilitation Sciences, Faculty of Health Sciences, Institute of Applied Health Sciences, McMaster University, Hamilton, Canada
| | - Lisa Carlesso
- School of Rehabilitation Sciences, Faculty of Health Sciences, Institute of Applied Health Sciences, McMaster University, Hamilton, Canada
| | - Julie Richardson
- School of Rehabilitation Sciences, Faculty of Health Sciences, Institute of Applied Health Sciences, McMaster University, Hamilton, Canada
| | - Harsha Shanthanna
- Anesthesia, St. Joseph's Hospital, McMaster University, Hamilton, Canada
| | - Luciana Macedo
- School of Rehabilitation Sciences, Faculty of Health Sciences, Institute of Applied Health Sciences, McMaster University, Hamilton, Canada
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11
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Bakaa N, Chen LH, Carlesso L, Richardson J, Macedo L. Reporting of post-operative rehabilitation interventions for Total knee arthroplasty: a scoping review. BMC Musculoskelet Disord 2021; 22:602. [PMID: 34193139 PMCID: PMC8247251 DOI: 10.1186/s12891-021-04460-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/08/2021] [Indexed: 12/17/2022] Open
Abstract
Objective The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation. Design: Scoping review Literature search A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library. Study selection criteria All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included. Data synthesis The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool. Results There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88–99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT. Conclusion The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER). Pre-registration OSF:https://osf.io/9ku8a/ Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04460-w.
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Affiliation(s)
- Nora Bakaa
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main St. W., Hamilton, ON, L8S 1C7, Canada.
| | - Lu Hsi Chen
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main St. W., Hamilton, ON, L8S 1C7, Canada
| | - Lisa Carlesso
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main St. W., Hamilton, ON, L8S 1C7, Canada
| | - Julie Richardson
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main St. W., Hamilton, ON, L8S 1C7, Canada
| | - Luciana Macedo
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main St. W., Hamilton, ON, L8S 1C7, Canada
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12
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Rowe E, Hassan E, Carlesso L, Astephen Wilson J, Gross DP, Fisher C, Hall H, Manson N, Thomas K, McIntosh G, Drew B, Rampersaud R, Macedo L. Predicting recovery after lumbar spinal stenosis surgery: A protocol for a historical cohort study using data from the Canadian Spine Outcomes Research Network (CSORN). Can J Pain 2020; 4:19-25. [PMID: 33987516 PMCID: PMC7942767 DOI: 10.1080/24740527.2020.1734918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background: Symptomatic lumbar spinal stenosis (SLSS) is a condition in which narrowing of the spinal canal results in entrapment and compression of neurovascular structures. Decompressive surgery, with or without spinal fusion, is recommended for those with severe symptoms for whom conservative management has failed. However, significant persistent pain, functional limitations, and narcotic use can affect up to one third of patients postsurgery. Aims: The aim of this study will be to identify predictors of outcomes 1-year post SLSS surgery with a focus on modifiable predictors. Methods: The Canadian Spine Outcomes Research Network (CSORN) is a large database of prospectively collected data on pre- and postsurgical outcomes among surgical patients. We include participants with a primary diagnosis of SLSS undergoing their first spine surgery. Outcomes are measured at 12 months after surgery and include back and leg pain, disability (Oswestry Disability Index, ODI), walking capacity (ODI item 4), health-related quality of life, and an overall recovery composite outcome (clinically important changes in pain, disability, and quality of life). Predictors include demographics (education level, work status, marital status, age, sex, body mass index), physical activity level, smoking status, previous conservative treatments, medication intake, depression, patient expectations, and other comorbidities. A multivariate partial least squares model is used to identify predictors of outcomes. Conclusion: Study results will inform targeted SLSS interventions, either for the selection of best candidates for surgery or the identification of targets for presurgical rehabilitation programs.
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Affiliation(s)
- Erynne Rowe
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth Hassan
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, Canada.,School of Rehabilitation, Université de Montréal, Montréal, Quebec, Canada
| | - Janie Astephen Wilson
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada.,Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Douglas P Gross
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Charles Fisher
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hamilton Hall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Neil Manson
- Canada East Spine Centre, Saint John, New Brunswick, Canada
| | - Ken Thomas
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Greg McIntosh
- Canadian Spine Society, Canadian Spine Outcomes Research Network, Toronto, Ontario, Canada
| | - Brian Drew
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Raja Rampersaud
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Luciana Macedo
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
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13
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14
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Matifat E, Perreault K, Roy JS, Aiken A, Gagnon E, Mequignon M, Lowry V, Décary S, Hamelin B, Ambrosio M, Farley N, Pelletier D, Carlesso L, Desmeules F. Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department. BMC Emerg Med 2019; 19:67. [PMID: 31707978 PMCID: PMC6842540 DOI: 10.1186/s12873-019-0277-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/11/2019] [Indexed: 11/26/2022] Open
Abstract
Background Overcrowding in emergency departments (ED) is a major concern worldwide. To answer increasing health care demands, new models of care including advanced practice physiotherapists (APP) have been implemented in EDs. The purpose of this study was to assess diagnostic, treatment and discharge plan concordance between APPs and ED physicians for patients consulting to the ED for minor musculoskeletal disorders (MSKD). Methods Patients presenting to two EDs in Montréal (Canada) with a minor MSKD were recruited and independently assessed by an APP and ED physician. Both providers had to formulate diagnosis, treatment and discharge plans. Cohen’s kappa (κ) and Prevalence and Bias Adjusted Kappas (PABAK) with associated 95%CI were calculated. Chi Square and t-tests were used to compare treatment, discharge plan modalities and patient satisfaction between providers. Results One hundred and thirteen participants were recruited, mean age was 50.3 ± 17.4 years old and 51.3% had an atraumatic MSKD. Diagnostic inter-rater agreement between providers was very good (κ = 0.81; 95% CI: 0.72–0.90). In terms of treatment plan, APPs referred significantly more participants to physiotherapy care than ED physicians (κ = 0.27; PABAK = 0.27; 95% CI: 0.07–0.45; p = 0.003). There was a moderate inter-rater agreement (κ = 0.46; PABAK = 0.64; 95% CI: 0.46–0.77) for discharge plans. High patient satisfaction was reported with no significant differences between providers (p = 0.57). Conclusion There was significant agreement between APPs and ED physicians in terms of diagnosis and discharge plans, but more discrepancies regarding treatment plans. These results tend to support the integration of APPs in ED settings, but further prospective evaluation of the efficiency of these types of models is warranted.
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Affiliation(s)
- E Matifat
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada.,CIUSSS Est-de-l'Île-de-Montréal, Québec, Canada
| | - K Perreault
- Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Québec, Québec, Canada.,Departement of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - J-S Roy
- Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Québec, Québec, Canada.,Departement of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - A Aiken
- Faculty of Health, Dalhousie University, Halifax, Canada
| | - E Gagnon
- CIUSSS Est-de-l'Île-de-Montréal, Québec, Canada
| | - M Mequignon
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada.,Université de Picardie Jules Verne, Amiens, France
| | - V Lowry
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada.,School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
| | - S Décary
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada
| | - B Hamelin
- CIUSSS Est-de-l'Île-de-Montréal, Québec, Canada
| | - M Ambrosio
- CIUSSS Centre-Ouest-de-l'Île-de-Montréal, Québec, Canada
| | - N Farley
- School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada.,CIUSSS Centre-Ouest-de-l'Île-de-Montréal, Québec, Canada
| | - D Pelletier
- Ordre Professionnel de la Physiothérapie du Québec, Montréal, Québec, Canada
| | - L Carlesso
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada.,School of Rehabilitation, Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - F Desmeules
- Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec, Canada. .,School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada.
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15
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Davis AM, Venkataramanan V, Bytautas-Sillanpää J, Perruccio AV, Wong R, Carlesso L, Webster F. Does the person's context influence engagement in life activities following primary knee replacement? Results from a Canadian prospective cohort study. BMJ Open 2017; 7:e015737. [PMID: 28821515 PMCID: PMC5724219 DOI: 10.1136/bmjopen-2016-015737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The impact of the context of a person's life on recovery from surgical interventions is not well understood. This study evaluated if people's social, environmental and biomedical context was associated with change in frequency in engagement in life activities after total knee replacement (TKR). METHODS 418 people aged 30+ years who had TKR were followed presurgery to 1 year postsurgery. The outcome was change in frequency in engagement in life activities measured by the Late Life Disability Index (LLDI). Predictor variables of interest evaluated in multivariable linear regression analysis were positive and negative life events (Life Experiences Survey), development of a new comorbidity, another joint replacement and complications after TKR surgery. RESULTS Mean age was 65 years, 36% were male; 22% and 21% had no comorbidity presurgery and postsurgery. Presurgery LLDI frequency was 69.6 (±11.4) and the mean change was 6.1 (±10.2). Thirty-four per cent and 65% reported at least one positive or negative life event. Seven per cent developed hypertension, 6% cardiovascular disease, 2% lung disease and 2% diabetes. Eleven per cent had a complication and 9% another hip or knee replaced. Smaller changes in LLDI frequency were associated with more negative life events (beta=-0.56; 95% CI -0.92 to-0.18) and complications (beta=-4.01; 95% CI -6.63 to -1.38) after adjusting for age, sex, education, body mass index, comorbidities presurgery, number of symptomatic joints and knee-specific pain and function, LLDI limitations and depression. A new comorbidity or another joint replacement was not associated with outcome in unadjusted or adjusted analysis. CONCLUSIONS Multifaceted life experiences shape the context of peoples' lives impacting their engagement in activities important for healthy living post-TKR.
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Affiliation(s)
- Aileen M Davis
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronta, Canada
| | - Viji Venkataramanan
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Canada
| | - Jessica Bytautas-Sillanpää
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Canada
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Anthony V Perruccio
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronta, Canada
| | - Rosalind Wong
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Canada
| | - Lisa Carlesso
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Canada
- Faculty of Medicine, School of Rehabilitation, Université de Montréal, Maisonneuve-Rosemont Hospital Research Centre, Montréal, Canada
| | - Fiona Webster
- Social and Behavioural Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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16
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MacKay C, Webster F, Venkataramanan V, Bytautas J, Perruccio AV, Wong R, Carlesso L, Davis AM. A prospective cohort study examining medical and social factors associated with engagement in life activities following total hip replacement. Osteoarthritis Cartilage 2017; 25:1032-1039. [PMID: 28193498 DOI: 10.1016/j.joca.2017.02.787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 01/31/2017] [Accepted: 02/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Studies show limited improvement in the frequency of engaging in life activities after joint replacement. However, there is a paucity of research that has examined factors, including other life events, which influence engagement following total hip replacement (THR). This research sought to identify factors associated with engaging in life activities following THR. METHODS A prospective cohort study was conducted with 376 people who had a THR for osteoarthritis (OA). Data were collected pre-surgery and 1 year post-surgery. The primary outcome was change in frequency in engagement in life activities (Late Life Disability Index (LLDI): higher scores indicate higher frequency of engagement (range 0-80)). Analyses included multivariable regression. Factors considered included: positive/negative life events, a new comorbidity, another joint replacement and complications post-surgery. RESULTS Participants' mean age was 64 years; 46% were male. 68% of participants had at least one comorbidity pre-surgery; 36% reported at least one new comorbidity after surgery. The mean change in LLDI frequency was an increase of 6.29 (±8.10). 36% reported one or more positive impact life events in the year following surgery; 63% reported one or more negative life events. The number of positive life events (beta = 1.24; 95% CI: 0.49, 1.99) was significantly associated with change in LLDI frequency after adjusting for age, sex, education, body mass index (BMI), comorbidities pre-surgery, number of symptomatic joints and pre-surgery pain and function, LLDI limitations and depression. CONCLUSIONS These findings highlight the significant influence of social factors and life circumstances on engagement in life activities following THR.
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Affiliation(s)
- C MacKay
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.
| | - F Webster
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - V Venkataramanan
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.
| | - J Bytautas
- Department of Public Health, University of Helsinki, Helsinki, Finland.
| | - A V Perruccio
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Arthritis Program, Division of Orthopaedics, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
| | - R Wong
- Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.
| | - L Carlesso
- School of Rehabilitation, Université de Montréal, Montreal, Quebec, Canada.
| | - A M Davis
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada; Rehabilitation Science Institute, University of Toronto, Toronto, Ontario, Canada.
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17
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Thoomes-de Graaf M, Thoomes EJ, Carlesso L, Kerry R, Rushton A. Adverse effects as a consequence of being the subject of orthopaedic manual therapy training, a worldwide retrospective survey. Musculoskelet Sci Pract 2017; 29:20-27. [PMID: 28284053 DOI: 10.1016/j.msksp.2017.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/21/2017] [Accepted: 02/23/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Physical therapists (PTs) use a range of manual therapy techniques developed to an advanced level through postgraduate orthopaedic manipulative physical therapy (OMPT) programmes. The aim of this study was to describe the adverse effects experienced by students after having techniques performed on them as part of their OMPT training. DESIGN A descriptive online survey of current students and recent graduates (≤5 years)m of OMPT programmes across the 22 Member Organisations of the International Federation of Orthopaedic Manipulative Physical Therapists. RESULTS The questionnaire was completed by 1640 respondents across 22 countries (1263 graduates, 377 students. Some 60% of respondents reported never having experienced adverse effects during their manual therapy training. Of the 40% who did, 66.4% reported neck pain, 50.9% headache and 32% low back pain. Most reports of neck pain started after a manipulation and/or mobilisation, of which 53.4% lasted ≤24 h, 38.1% > 24 h but <3 months and 13.7% still experienced neck pain to date. A small percentage of respondents (3.3%) reported knowing of a fellow student experiencing a major adverse effect. CONCLUSION Mild to moderate adverse effects after practising manual therapy techniques are commonly reported, but usually resolve within 24 h. However, this survey has identified the reported occurrence of major adverse effects that warrant further investigation.
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Affiliation(s)
- M Thoomes-de Graaf
- Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands; OMPT Clinic Fysio-Experts, Hazerswoude, The Netherlands
| | - E J Thoomes
- OMPT Clinic Fysio-Experts, Hazerswoude, The Netherlands.
| | - L Carlesso
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Centre de recherche de l'Hôpital Maisonneuve-Rosemont, Montréal, Canada
| | - R Kerry
- Department of Philosophy, University of Nottingham, Nottingham, United Kingdom
| | - A Rushton
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, United Kingdom
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18
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MacDermid JC, Walton DM, Bobos P, Lomotan M, Carlesso L. A Qualitative Description of Chronic Neck Pain has Implications for Outcome Assessment and Classification. Open Orthop J 2016; 10:746-756. [PMID: 28217199 PMCID: PMC5301418 DOI: 10.2174/1874325001610010746] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/03/2016] [Accepted: 12/07/2016] [Indexed: 02/01/2023] Open
Abstract
Background: Neck pain is common, but few studies have used qualitative methods to describe it. Purpose: To describe the quality, distribution and behavior of neck pain. Methods: Sixteen people (15 females; mean age = 33 years (range = 20-69)) with neck pain >3 months were interviewed using a semi-structured guide. Interview data were recorded and transcribed verbatim. Descriptive content analysis was performed by two authors. Participants then completed an electronic descriptive pain tool, placing icons (word and icon descriptors to describe quality) on anatomic diagrams to identify location of pain, and intensity ratings at each location. This data was triangulated with interviews. Results: Aching pain and stiffness in the posterior neck and shoulder region were the most common pain complaints. All patients reported more than one pain quality. Associated headache was common (11/16 people); but varied in location and pain quality; 13/16 reported upper extremity symptoms. Neuropathic characteristics (burning) or sensory disturbance (numbness/tingling) occurred in some patients, but were less common. Activities that involved lifting/carrying and psychological stress were factors reported as exacerbating pain. Physical activity was valued as essential to function, but also instigated exacerbations. Concordance between the structured pain tool and interviews enhanced trustworthiness of our results. Integrating qualitative findings with a previous classification system derived a 7-axis neck pain classification: source/context, sample subgroup, distribution, duration, episode pattern, pain/symptom severity, disability/participation restriction. Conclusions: Qualitative assessment and classification should consider the multiple dimensions of neck pain.
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Affiliation(s)
- Joy C MacDermid
- School of Physical Therapy, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada; Clinical Research Lab, Hand and Upper Limb Centre, St. Joseph's Health Care London, 268 Grosvenor Street, London, Ontario, N6A 4L6, Canada
| | - David M Walton
- School of Physical Therapy, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada
| | - Pavlos Bobos
- School of Physical Therapy, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada
| | - Margaret Lomotan
- School of Physical Therapy, Western University, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada
| | - Lisa Carlesso
- Faculty of Medicine, University of Montreal, 2900 Boulevard Edouard-Montpetit, Montréal, QC H3T 1J4, Canada
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Kerry R, Rushton A, Flynn T, Hing W, Carlesso L, Rivett D. Response to – Risk reduction of serious complications from manual therapy: Are we reducing the risk? ACTA ACUST UNITED AC 2014; 19:e3-4. [DOI: 10.1016/j.math.2014.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
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20
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Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention. ACTA ACUST UNITED AC 2013; 19:222-8. [PMID: 24378471 DOI: 10.1016/j.math.2013.11.005] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 11/11/2013] [Accepted: 11/16/2013] [Indexed: 12/16/2022]
Abstract
A consensus clinical reasoning framework for best practice for the examination of the cervical spine region has been developed through an iterative consultative process with experts and manual physical therapy organisations. The framework was approved by the 22 member countries of the International Federation of Orthopaedic Manipulative Physical Therapists (October 2012). The purpose of the framework is to provide guidance to clinicians for the assessment of the cervical region for potential of Cervical Arterial Dysfunction in advance of planned management (inclusive of manual therapy and exercise interventions). The best, most recent scientific evidence is combined with international expert opinion, and is presented with the intention to be informative, but not prescriptive; and therefore as an aid to the clinician's clinical reasoning. Important underlying principles of the framework are that 1] although presentations and adverse events of Cervical Arterial Dysfunction are rare, it is a potentially serious condition and needs to be considered in musculoskeletal assessment; 2] manual therapists cannot rely on the results of one clinical test to draw conclusions as to the presence or risk of Cervical Arterial Dysfunction; and 3] a clinically reasoned understanding of the patient's presentation, including a risk:benefit analysis, following an informed, planned and individualised assessment, is essential for recognition of this condition and for safe manual therapy practice in the cervical region. Clinicians should also be cognisant of jurisdictionally specific requirements and obligations, particularly related to patient informed consent, when intending to use manual therapy in the cervical region.
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Affiliation(s)
- A Rushton
- School of Sport, Exercise and Rehabilitation Science, College of Life and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
| | - D Rivett
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - L Carlesso
- University Health Network, Toronto Western Research Institute, Toronto, Ontario M5T 2S8, Canada
| | - T Flynn
- Rocky Mountain University of Health Professions, 561 East 1860 South, Provo, UT 84606, USA
| | - W Hing
- Bond University, Faculty of Health Sciences and Medicine, Bond University Institute of Health and Sport, Gold Coast, Robina, Queensland 4226, Australia
| | - R Kerry
- Division of Physiotherapy Education, School of Health Sciences, University of Nottingham, Nottingham NG5 1PB, United Kingdom
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21
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Macdermid JC, Walton DM, Côté P, Santaguida PL, Gross A, Carlesso L. Use of outcome measures in managing neck pain: an international multidisciplinary survey. Open Orthop J 2013; 7:506-20. [PMID: 24115972 PMCID: PMC3793628 DOI: 10.2174/1874325001307010506] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 03/19/2013] [Accepted: 03/19/2013] [Indexed: 01/10/2023] Open
Abstract
Purpose: To determine the outcome measures practice patterns in the neck pain management of various health disciplines. Methods: A survey of 381 clinicians treating patients with neck pain was conducted. Results: Respondents were more commonly male (54%) and either chiropractors (44%) or physiotherapists (32%). The survey was international (24 countries with Canada having the largest response (44%)). The most common assessment was a single-item pain assessment (numeric or visual analog) used by 75% of respondents. Respondents sometimes or routinely used the Neck Disability Index (49%), the Patient Specific Functional Scale (28%), and the Disabilities of the Arm, Shoulder and Hand (32%). Work status was recorded in terms of time lost by more than 50% of respondents, but standardized measures of work limitations or functional capacity testing were rarely used. The majority of respondents never used fear of movement, psychological distress, quality of life, participation measures, or global ratings of change (< 10% routinely use). Use of impairment measurers was prevalent, but the type selected was variable. Quantitative sensory testing was used sometimes or routinely by 53% of respondents, whereas 26% never used it. Ratings of segmental joint mobility were commonly used to assess motion (44% routinely use), whereas 66% of respondents never used inclinometry. Neck muscle strength, postural alignment and upper extremity coordination were assessed sometimes or routinely by a majority of respondents (>56%). With the exception of numeric pain ratings and verbal reporting of work status, all outcomes measures were less frequently used by physicians. Years of practice did not affect practice patterns, but reimbursement did affect selection of some outcome measures. Conclusions: Few outcome measures are routinely used to assess patients with neck pain other than a numeric pain rating scale. A comparison of practice patterns to current evidence suggessts overutilization of some measures that have questionable reliability and underutilization of some with better supporting evidence. This practice analysis suggests that there is substantial need to implement more consistent outcome measurement in practice. International consensus and better clinical measurement evidence are needed to support this.
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Affiliation(s)
- Joy C Macdermid
- School of Rehabilitation Sciences, McMaster University, Hamilton Ontario Canada, and Clinical Research Lab, Hand and Upper Limb Centre, St. Joseph's Health Centre, London, Ontario, Canada
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22
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Peloso PM, Khan M, Gross AR, Carlesso L, Santaguida L, Lowcock J, MacDermid JC, Walton D, Goldsmith CH, Langevin P, Shi Q. Pharmacological Interventions Including Medical Injections for Neck Pain: An Overview as Part of the ICON Project. Open Orthop J 2013; 7:473-93. [PMID: 24155805 PMCID: PMC3802125 DOI: 10.2174/1874325001307010473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/25/2013] [Accepted: 04/04/2013] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To conduct an overview (review-of-reviews) on pharmacological interventions for neck pain. SEARCH STRATEGY Computerized databases and grey literature were searched from 2006 to 2012. SELECTION CRITERIA Systematic reviews of randomized controlled trials (RCT) in adults with acute to chronic neck pain reporting effects of pharmacological interventions including injections on pain, function/disability, global perceived effect, quality of life and patient satisfaction. DATA COLLECTION & ANALYSIS Two independent authors selected articles, assessed risk of bias and extracted data The GRADE tool was used to evaluate the body of evidence and an external panel provided critical review. MAIN RESULTS We found 26 reviews reporting on 47 RCTs. Most pharmacological interventions had low to very low quality methodologic evidence with three exceptions. For chronic neck pain, there was evidence of: a small immediate benefit for eperison hydrochloride (moderate GRADE, 1 trial, 157 participants);no short-term pain relieving benefit for botulinum toxin-A compared to saline (strong GRADE; 5 trial meta-analysis, 258 participants) nor for subacute/chronic whiplash (moderate GRADE; 4 trial meta-analysis, 183 participants) including reduced pain, disability or global perceived effect; andno long-term benefit for medial branch block of facet joints with steroids (moderate GRADE; 1 trial, 120 participants) over placebo to reduce pain or disability; REVIEWERS' CONCLUSIONS While in general there is a lack of evidence for most pharmacological interventions, current evidence is against botulinum toxin-A for chronic neck pain or subacute/chronic whiplash; against medial branch block with steroids for chronic facet joint pain; but in favour of the muscle relaxant eperison hydrochloride for chronic neck pain.
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Walton DM, Macdermid JC, Santaguida PL, Gross A, Carlesso L. Results of an International Survey of Practice Patterns for Establishing Prognosis in Neck Pain: The ICON Project. Open Orthop J 2013; 7:387-95. [PMID: 24115968 PMCID: PMC3793579 DOI: 10.2174/1874325001307010387] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 10/12/2012] [Accepted: 10/12/2012] [Indexed: 11/22/2022] Open
Abstract
Results of an international survey of health care providers for neck pain are reported. The survey specifically collected self-reported practice patterns for establishing a prognosis in neck pain. Over 440 responses from 27 countries were collected. Descriptive results indicate that respondents assigned large prognostic impact to factors including mechanism of injury and psychological or behavioral constructs. Range of motion, age and sex were routinely collected despite relatively moderate impact on prognosis. A comparison between chiropractic and manual/physical therapy groups showed differences in practice patterns that were unlikely to affect prognostic accuracy. The results suggest a gap exists between current best-evidence and actual practice when the goal is to establish a prognosis in neck pain.
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Affiliation(s)
- David M Walton
- School of Physical Therapy, Western University, London Ontario, Canada
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24
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Walton DM, Carroll LJ, Kasch H, Sterling M, Verhagen AP, Macdermid JC, Gross A, Santaguida PL, Carlesso L. An Overview of Systematic Reviews on Prognostic Factors in Neck Pain: Results from the International Collaboration on Neck Pain (ICON) Project. Open Orthop J 2013; 7:494-505. [PMID: 24115971 PMCID: PMC3793581 DOI: 10.2174/1874325001307010494] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 01/08/2023] Open
Abstract
Given the challenges of chronic musculoskeletal pain and disability, establishing a clear prognosis in the acute stage has become increasingly recognized as a valuable approach to mitigate chronic problems. Neck pain represents a condition that is common, potentially disabling, and has a high rate of transition to chronic or persistent problems. As a field of research, prognosis in neck pain has stimulated several empirical primary research papers, and a number of systematic reviews. As part of the International Consensus on Neck (ICON) project, we sought to establish the general state of knowledge in the area through a structured, systematic review of systematic reviews (overview). An exhaustive search strategy was created and employed to identify the 13 systematic reviews (SRs) that served as the primary data sources for this overview. A decision algorithm for data synthesis, which incorporated currency of the SR, risk of bias assessment of the SRs using AMSTAR scoring and consistency of findings across SRs, determined the level of confidence in the risk profile of 133 different variables. The results provide high confidence that baseline neck pain intensity and baseline disability have a strong association with outcome, while angular deformities of the neck and parameters of the initiating trauma have no effect on outcome. A vast number of predictors provide low or very low confidence or inconclusive results, suggesting there is still much work to be done in this field. Despite the presence of multiple SR and this overview, there is insufficient evidence to make firm conclusions on many potential prognostic variables. This study demonstrates the challenges in conducting overviews on prognosis where clear synthesis critieria and a lack of specifics of primary data in SR are barriers.
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Affiliation(s)
- David M Walton
- Faculty of Health Sciences, The University of Western Ontario, London Ontario, Canada
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Abstract
The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) aims to achieve worldwide promotion of excellence and unity in clinical and academic standards for manual and musculoskeletal physical therapists. To this end, IFOMPT has sponsored several conference panel sessions and a survey of Member Organizations (MOs) and Registered Interest Groups (RIGs) regarding current cervical spine manipulation and pre-manipulative screening practice in each country. The purpose of this study was to determine common elements of cervical spine manipulative practice and pre-manipulative screening between countries. In late 2007, a questionnaire investigating recommended pre-manipulative screening protocol/guideline use, informed consent regarding risks, screening procedures, and treatment/manipulation technique was sent to all twenty MOs and five RIGs. The response rate was 88%. The main findings of the survey included: 77% of respondent organizations use pre-manipulative guidelines, with Australian guidelines the most frequently adopted internationally (36%); recommendations concerning the provision of information about the possibility of serious adverse events is not standard practice in all countries (50%); positional tests for vertebrobasilar insufficiency are used by all respondent organizations; craniovertebral ligament testing is sometimes taught as a pre-manipulative screening tool (36%); the use of upper cervical spine manipulation has declined in some countries (41%); and of the respondent organizations that continue to teach upper cervical manipulation, most (70%) minimize the rotation component. The findings of this research will inform an IFOMPT international standard for screening the cervical region prior to orthopaedic manual therapy intervention. The development of an IFOMPT endorsed document will be of assistance to manual therapy clinicians worldwide in safely managing disorders of the cervical spine.
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Affiliation(s)
- Lisa Carlesso
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Carlesso L, Bartlett DJ, Padfield B, Chesworth BM. Cervical Manipulation and Informed Consent: Canadian Manipulative Physiotherapists' Opinions on Communicating Risk. Physiother Can 2007. [DOI: 10.3138/ptc.59.2.86] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: The study objective was to generate an information sheet for Canadian manipulative physical therapists (CMPTs) to use when seeking informed consent for high-velocity, low-amplitude cervical manipulation. Methods: A cervical manipulation information sheet (CMIS) was created with five sections: Introduction, Benefits, Risks, Procedures and Effectiveness. The content of the information sheet was generated using the Delphi method, followed by a mail-out survey to a random sample of CMPTs (N = 307) to determine the information sheet's acceptability and clinical utility. The proportion of CMPTs who agreed with the content of the information sheet and the proportion of CMPTs who indicated a willingness to use the sheet clinically were calculated. Results: The survey response rate was 74 per cent. The proportion (95 per cent confidence interval) of respondents who agreed with the content of the CMIS and approved its clinical acceptability was 0.95 (0.94-0.96) and 0.61 (0.58-0.64), respectively. Written comments from the CMPTs reflected concern about wording in the Risks section. Conclusions: Our results suggest that CMPTs agreed with the content of the CMIS but not how it was written. Physical therapists should consider the CMIS a proposed guideline for clinician use. Ideally, a patient version should also be created.
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