Christophe Demoulin

Pressure pain thresholds of tender point sites in patients with fibromyalgia and in healthy controls

Pressure pain threshold (PPT) is defined as the minimum force applied which induces pain. This measure has proven to be commonly useful in evaluating tenderness symptom. Our aim was to study the intra‐examiner reproducibility of PPT measurement, define cutoffs in normal groups, and compare these results with patients with fibromyalgia (FM). Fifty healthy females, 50 healthy males, and 20 patients with FM participated in the study. PPTs were assessed for 18 specific tender point sites by a dolorimeter. The intra‐individual coefficient of variation determined by a test—retestPPT measurement procedure with 3‐days interval reached, respectively, 17% and 13% in healthy females and males, versus 24% in patients with FM. PPTs were significantly lower in healthy females than in healthy males (p<0.01). Statistical analysis failed to show any differences between the dominant and nondominant side for both normal groups. PPTs were lower over all examined areas in patients with FM than those obtained in healthy females (p<0.000). Lower cutoff levels were calculated from normal values for all specific tender point sites. On average, 14 tender point sites in patients with FM were under the established lower cutoffs. In conclusion, pressure pain sensitivity was influenced by the anatomical localization of tender point and gender differences. Lowest PPTs were localized in trapezius, occiput, anterior cervical, and second rib. The reduction of total tender point score in patients with FM averaged 60% comparatively with normal values. PPT reproducibility and discrimination between the two groups were optimal for the gluteal and knee sites.

Measures of function in low back pain/disorders: Low Back Pain Rating Scale (LBPRS), Oswestry Disability Index (ODI), Progressive Isoinertial Lifting Evaluation (PILE), Quebec Back Pain Disability Scale (QBPDS), and Roland-Morris Disability Questionnaire (RDQ).

Treatment of patients with chronic low back pain and its evolving disability primarily tries to improve the patients’ levels of activities and participation. Mostly, self-reported questionnaires have been used for clinical as well as research purposes to assess daily functioning (1,2), of which the most commonly used will be discussed below. However, this information may not necessarily reflect the real capacity of a patient’s performance. A recent review showed that the correlation of self-reported disability and physical activity level was at best moderate for patients with chronic low back pain (3). In order to improve objectivity, measures of body function, e.g., spinal mobility and lumbar extensor muscle strength, have been used, although the correlation with the level of disability is very weak (4,5). Furthermore, there are major concerns about reliability and validity (6–8). Besides the self-reported disability measures, many have urged to use more objective and direct measures of low back pain–specific functional capacity (5,9,10). Capacity is defined as the highest probable level of functioning that a person may reach in an activity domain at any given moment in a standardized environment. Although there is still no consensus for the definition of functional capacity evaluation (FCE), in the past decades, several FCE measures have been developed, of which the Isernhagen Work Systems Functional Capacity Evaluation (IWS-FCE) is among the most frequently used (11,12). However, recently published psychometric data have shown that some of the tasks included in the IWS-FCE are not reliable (13,14). Unfortunately, the entire sequence of tasks in, for example, the IWS-FCE, is time consuming and expensive, as is the training of the test observer. Therefore, we have decided not to include these measures in this review. Nevertheless, in order to keep up with, for example, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations to evaluate several core outcome domains, including physical functioning (9), we wanted to include easy to use performance tasks. Several tasks have been described (8,15–17), but most of them are not low back pain specific, and some, such as the Back Performance Scale, show insufficient factor structure, as in this measure the quality of the performance is also scored (1,18). Therefore, we decided only to include a performance task that assesses lifting, an activity that specifically might be hampered by low back pain. For the selection of the self-reported disability questionnaires and lifting performance tasks, we only selected questionnaires/tests that are low back pain specific and of which all psychometric, including responsiveness, properties have been studied in relevant low back pain populations and published in peer-reviewed journals. Other criteria for selection were: being available in at least English and for performance task measures, easy to administer, inexpensive, and not time consuming when used in clinical practice.

Translation validation of a new back pain screening questionnaire (the STarT Back Screening Tool) in French

BackgroundLow back pain (LBP) is a major public health problem and the identification of individuals at risk of persistent LBP poses substantial challenges to clinical management. The STarT Back questionnaire is a validated nine-item patient self-report questionnaire that classifies patients with LBP at low, medium or high-risk of poor prognosis for persistent non-specific LBP. The objective of this study was to translate and cross-culturally adapt the English version of the STarT Back questionnaire into French.MethodsThe translation was performed using best practice translation guidelines. The following phases were performed: contact with the STarT Back questionnaire developers, initial translations (English into French), synthesis, back translations, expert committee review, test of the pre-final version on 44 individuals with LBP, final version.ResultsThe linguistic translation required minor semantic alterations. The participants interviewed indicated that all items of the questionnaire were globally clear and comprehensible. However, 6 subjects (14%) wondered if two questions were related to back pain or general health. After discussion within the expert committee and with the developer of the STarT Back tool, it was decided to modify the questionnaire and to add a reference to back pain in these two questions.ConclusionsThe French version of the STarT Back questionnaire has been shown to be comprehensible and adapted to the French speaking general population. Investigations are now required to test the psychometric properties (reliability, internal and external validity, responsiveness) of this translated version of the questionnaire.

Effectiveness of a semi-intensive multidisciplinary outpatient rehabilitation program in chronic low back pain

OBJECTIVES To evaluate the efficacy of a semi-intensive multidisciplinary outpatient program complying with the requirements of the Belgian National Institute for Health and Disability Insurance and intended for patients with chronic low back pain. METHODS We included 262 patients with nonspecific chronic low back pain, among whom 136 (73 women and 63 men) with a mean pain duration of 11.3 years completed the outpatient program (36 sessions each lasting 2h). The program consisted of education about back-sparing techniques, interventions by an occupational therapist and psychologist, and physical reconditioning. Three sessions (sessions 1, 18, and 36) were used to evaluate pain intensity, functional impairment, kinesiophobia, cognitive knowledge, knowledge of appropriate spinal movement technique, and physical performance (trunk muscle strength and endurance, mobility of the pelvis and lumbar spine, and aerobic capacity). RESULTS All study variables were significantly improved at study completion compared to baseline: pain intensity was decreased by 44%, functional impairment by 40%, and kinesiophobia by 11% whereas knowledge was improved by 59%, back-sparing technique by 95%, trunk muscle strength by 40% on average, trunk extensor muscle endurance by 90%, mobility by 8%, and aerobic capacity by 18%. CONCLUSIONS A semi-intensive multidisciplinary outpatient program was beneficial in patients with chronic low back pain. Careful patient selection and increased patient involvement in the program may help to improve adherence.

Relationship between different measures of pain-related fear and physical capacity of the spine in patients with chronic low back pain

BACKGROUND CONTEXT It has been controversially stated that pain-related fear is a more important determining factor for disability in chronic low back pain (CLBP) than pain or physical impairment in itself. So far, the relationship between psychological and physiological determinants of chronic pain, that is, pain-related fear and physiological abilities, remains unclear. PURPOSE To evaluate whether pain-related fear assessed by different tools (both task specific and non task specific) is related to physical capacity measured by specific spine tests and, secondarily, to explore the relationship between different pain-related fear assessment tools. STUDY DESIGN/SETTING Cross-sectional study. PATIENT SAMPLE Fifty patients with CLBP (50% women; meanage [standard deviationage]: 44.2 [9.5 years]). OUTCOME MEASURES Physical capacity by means of three specific spine tests, that is, the finger-floor distance test (flexibility), a maximal isometric strength test of trunk extensor muscles (strength), and the Sorensen test (endurance). Pain-related fear by means of self-report measures, that is, the Tampa Scale for Kinesiophobia (TSK), the Photograph Series of Daily Activities (PHODA), and a fear visual analog scale (FVAS) tailored to the spine tests. METHODS Participants were asked to complete the TSK and PHODA and to perform the three spine tests. Right before performing each of the spine tests, an FVAS was filled out. Linear regression analyses controlling for gender and age were performed to study the association between the pain-related fear measurements and the results of the spine tests. To investigate the relationship between the pain-related fear measurements, correlation tests were performed. RESULTS The linear regression analyses revealed that neither the TSK and PHODA scores nor the FVAS scores were significantly related to the physical capacity measurements. The correlational tests showed no significant correlation between the PHODA, TSK, and FVAS scores. CONCLUSIONS The present study shows that neither the task-specific tool (FVAS) nor the non task-specific questionnaires (TSK and PHODA) were significantly correlated to the spine tests in patients with CLBP. This is contrary to earlier evidence according to which physical capacity is inversely related to the level of pain-related fear, and it suggests that one should not draw conclusions about physical capacity based on pain-related fear scores. Furthermore, the different assessment tools for pain-related fear were surprisingly not correlated with each other.

Validity and reliability of the French version of the STarT Back screening tool for patients with low back pain.

Study Design. Observational prospective study. Objective. Our objective was to assess the reliability and validity of the French version of the Keele STarT Back Screening Tool (SBST). Summary of Background Data. The SBST is a recently validated tool developed to identify subgroups of patients with low back pain (LBP) to guide early secondary prevention in primary care. Methods. Outpatients 18 years or older with LBP, attending a rehabilitation center, a back school, a private physiotherapy unit, or a fitness center were included. Patients were assessed through the SBST, Roland-Morris Disability Questionnaire, Örebro Musculoskeletal Pain Screening Questionnaire, Medical Outcomes Survey Short Form-36 questionnaire, and a pain visual analogue scale. Test-retest reliability was assessed with Kappa score or the intraclass correlation coefficient, internal consistency of the Psychological subscale with the Cronbach &agr; coefficient, construct validity with the Spearman correlation coefficient, and floor and ceiling effects by percentage frequency of lowest or highest possible score achieved by respondents. Results. One hundred eight patients with LBP were included. The test-retest reliability of the SBST total score was excellent with an intraclass correlation coefficient of 0.90 (0.81–0.95). The Cronbach &agr; coefficient was 0.73 showing a good internal consistency for the Psychological subscale. High Spearman correlation coefficients of 0.74 between SBST and Roland-Morris Disability Questionnaire, and 0.74 between the SBST and Örebro Musculoskeletal Pain Screening Questionnaire were observed. As expected, low-to-moderate correlations were observed between the SBST total score and some dissimilar measures of the Short-Form 36. The lowest possible SBST score was observed for 8 patients (7.4%), whereas only 3 patients (2.8%) had the highest possible SBST score. Conclusion. The French version of the SBST is a reliable and valid questionnaire consistent with the original English version. Therefore, this new version may help French-speaking clinicians and scientists to stratify patients with LBP. Level of Evidence: 2

Cryotherapy in rheumatic diseases

Joint Bone Spine - In Press.Proof corrected by the author Available online since samedi 26 novembre 2011

Benefits of a Physical Training Program After Back School for Chronic Low Back Pain Patients

Objectives: Compare a treatment combining a back school program and physical training with a treatment consisting of only a back school program undertaken by chronic low back pain [CLBP] patients. Methods: Forty CLBP patients [21 females] completed an educational back school program. Once ended, 17 subjects [the Education-Physical Group [EPG]] started physical training sessions attended twice a week [90 minutes] for six weeks. The others constituted the Education Group [EG]. All subjects performed three tests: the pain visual analog scale, the Dallas questionnaire assessing quality of life, and an ergonomic test at the beginning [Day [D] 1], at the end [D21] of the back school program, and three months later [D120]. The EPG also carried out physical tests at the start and at the end of the physical training. Results: At D21, no significant difference in pain and Dallas scores appeared, although patients of both groups performed the ergonomic test significantly better. At D120, the decrease of pain intensity and the quality of life improvement were significant in both groups [P < 0.05]. The extent of the pain intensity decrease was significantly higher in the EPG compared to the EG. The EPG displayed improvements in most physical assessments [P < 0.05]. Only the increase of knee extensors strength correlated significantly with the improvements of quality of life and ergonomic function scores. Conclusions: This study supports positive effects of a back school program for CLBP patients. Additional physical training sessions lead to lower pain intensity, greater improvement of quality of life than back school sessions only, as well as improvement of muscle performances. The increase of the knee extensors strength might have helped to decrease the pain and improve the quality of life.

English translation and validation of the SarQoL®, a quality of life questionnaire specific for sarcopenia

Background the first quality of life questionnaire specific to sarcopenia, the SarQoL®, has recently been developed and validated in French. To extend the availability and utilisation of this questionnaire, its translation and validation in other languages is necessary. Objective the purpose of this study was therefore to translate the SarQoL® into English and validate the psychometric properties of this new version. Design cross-sectional. Setting Hertfordshire, UK. Subjects in total, 404 participants of the Hertfordshire Cohort Study, UK. Methods the translation part was articulated in five stages: (i) two initial translations from French to English; (ii) synthesis of the two translations; (iii) backward translations; (iv) expert committee to compare the backward translations with the original questionnaire and (v) pre-test. To validate the English SarQoL®, we assessed its validity (discriminative power, construct validity), reliability (internal consistency, test–retest reliability) and floor/ceiling effects. Results the SarQoL® questionnaire was translated without any major difficulties. Results indicated a good discriminative power (lower score of quality of life for sarcopenic subjects, P = 0.01), high internal consistency (Cronbach’s alpha of 0.88), consistent construct validity (high correlations found with domains related to mobility, usual activities, vitality, physical function and low correlations with domains related to anxiety, self-care, mental health and social problems) and excellent test– retest reliability (intraclass coefficient correlation of 0.95, 95%CI 0.92–0.97). Moreover, no floor/ceiling has been found. Conclusions a valid SarQoL® English questionnaire is now available and can be used with confidence to better assess the disease burden associated with sarcopenia. It could also be used as a treatment outcome indicator in research.

Physical Therapists' Knowledge, Attitudes, and Beliefs about Physical Activity: A Prerequisite to their Role in Physical Activity Promotion?

Background. The promotion of physical activity (PA) is widely recognized as a major component of the prevention and management of several chronic diseases. As experts in human movement, physical therapists (PTs) are logical agents for the promotion of PA. Nevertheless, to date only few studies have investigated factors that influence PA promotion. Objectives. This study aimed to analyze the relationships between physical therapist knowledge, attitudes, and beliefs about PA, and their own self‐reported PA promotion. Design. A sample of 185 PTs (male = 102) completed a cross‐sectional survey through an online questionnaire. It included 25 multiple choice, Likert scale, and open‐ended questions related to (1) personal characteristics, (2) knowledge, attitudes, and beliefs about PA, and (3) self‐reported PA promotion by PTs. A deductive and inductive content analysis of the open‐ended questions was also performed. Results. The questionnaire revealed that 99% of PTs agreed (n = 30) or completely agreed (n = 154) with the fact that they have to contribute to PA promotion in their patients. Significant correlations were found between physical therapist knowledge of the definition of PA, the benefits of PA, and their self‐reported PA promotion (0.251, P < .01 and 0.180, P < .05, respectively). Additional multivariate analysis of the predictors of the self‐reported PA promotion exposed significant univariate effects of knowledge, attitudes, and beliefs about PA (P < .01). Conclusion. Although the role of PTs in PA promotion seems evident, this survey underlines important misconceptions about PA within this group of health care professionals. Significant relationships between physical therapist knowledge, attitudes, and beliefs about PA and self‐reported promotion of PA highlight the need for physical therapist education programs to emphasize teaching the fundamentals of PA.