Clermont E. Dionne

A Consensus Approach Toward the Standardization of Back Pain Definitions for Use in Prevalence Studies

Study Design. A modified Delphi study conducted with 28 experts in back pain research from 12 countries. Objective. To identify standardized definitions of low back pain that could be consistently used by investigators in prevalence studies to provide comparable data. Summary of Background Data. Differences in the definition of back pain prevalence in population studies lead to heterogeneity in study findings, and limitations or impossibilities in comparing or summarizing prevalence figures from different studies. Methods. Back pain definitions were identified from 51 articles reporting population-based prevalence studies, and dissected into 77 items documenting 7 elements. These items were submitted to a panel of experts for rating and reduction, in 3 rounds (participation: 76%). Preliminary results were presented and discussed during the Amsterdam Forum VIII for Primary Care Research on Low Back Pain, compared with scientific evidence and confirmed and fine-tuned by the panel in a fourth round and the preparation of the current article. Results. Two definitions were agreed on a minimal definition (with 1 question covering site of low back pain, symptoms observed, and time frame of the measure, and a second question on severity of low back pain) and an optimal definition that is made from the minimal definition and add-ons (covering frequency and duration of symptoms, an additional measure of severity, sciatica, and exclusions) that can be adapted to different needs. Conclusion. These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries.

Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis.

Background Different diagnostic imaging modalities, such as ultrasonography (US), MRI, MR arthrography (MRA) are commonly used for the characterisation of rotator cuff (RC) disorders. Since the most recent systematic reviews on medical imaging, multiple diagnostic studies have been published, most using more advanced technological characteristics. The first objective was to perform a meta-analysis on the diagnostic accuracy of medical imaging for characterisation of RC disorders. Since US is used at the point of care in environments such as sports medicine, a secondary analysis assessed accuracy by radiologists and non-radiologists. Methods A systematic search in three databases was conducted. Two raters performed data extraction and evaluation of risk of bias independently, and agreement was achieved by consensus. Hierarchical summary receiver-operating characteristic package was used to calculate pooled estimates of included diagnostic studies. Results Diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears was high with overall estimates of sensitivity and specificity over 0.90. As for partial RC tears and tendinopathy, overall estimates of specificity were also high (>0.90), while sensitivity was lower (0.67–0.83). Diagnostic accuracy of US was similar whether a trained radiologist, sonographer or orthopaedist performed it. Conclusions Our results show the diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears. Since full thickness tear constitutes a key consideration for surgical repair, this is an important characteristic when selecting an imaging modality for RC disorder. When considering accuracy, cost, and safety, US is the best option.

The burden of wait for knee replacement surgery: effects on pain, function and health-related quality of life at the time of surgery

OBJECTIVE To examine the change in pain and function related to the knee scheduled for surgery, change in health-related quality of life (HRQoL) and change in contralateral knee pain during pre-surgery wait up until time of surgery. METHODS One hundred and fifty-three patients scheduled for knee replacement were recruited from three hospitals in Québec City, Canada, and followed until surgery. Pre-surgery wait, defined as the time between enrolment on the pre-surgery wait list and surgery, was considered in five categories (< or =3, >3-6, >6-9, >9-12 and >12 months). Pain and functional limitations were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the medical outcomes study 36-item short form health survey. RESULTS Mean pre-surgery wait time was 183 (s.d. 121.9) days. Subjects having waited >9-12 months showed significant deterioration of the WOMAC pain (-9.9; 95% CI -19.2, -0.54) and function (-11.1; 95% CI -18.7, -3.4) scores. On the HRQoL SF-36 physical functioning scale, a significant deterioration was seen in subjects having waited >9-12 months (-11.3; 95% CI -18.4, -4.2) and >12 months (-7.1; 95% CI -12.9, -1.3). On the contralateral knee WOMAC pain score, a significant deterioration was observed in subjects having waited >6-9 months (-10.4; 95% CI -16.9, -3.9) and >12 months (-10.7; 95% CI -19.7, -1.7). CONCLUSION Pre-surgery wait time has a negative significant impact on pain, function and HRQoL at the time of surgery. The magnitude of deterioration seen in this study may be clinically important. The effects of this pre-surgery deterioration on post-surgery outcomes need to be investigated.

Cumulative Incidence of Functional Decline After Minor Injuries in Previously Independent Older Canadian Individuals in the Emergency Department

To estimate the cumulative incidence of functional decline in independent older adults 3 and 6 months after a minor injury treated in the emergency department (ED) and to identify predictors of this functional decline.

Consensus on Exercise Reporting Template (CERT): Explanation and Elaboration Statement

Exercise is effective for prevention and management of acute and chronic health conditions. However, trial descriptions of exercise interventions are often suboptimal, leaving readers unclear about the content of effective programmes. To address this, the 16-item internationally endorsed Consensus on Exercise Reporting Template (CERT) was developed. The aim is to present the final template and provide an Explanation and Elaboration Statement to operationalise the CERT. Development of the CERT was based on the EQUATOR Network methodological framework for developing reporting guidelines. We used a modified Delphi technique to gain consensus of international exercise experts and conducted 3 sequential rounds of anonymous online questionnaires and a Delphi workshop. The 16-item CERT is the minimum data set considered necessary to report exercise interventions. The contents may be included in online supplementary material, published as a protocol or located on websites and other electronic repositories. The Explanation and Elaboration Statement is intended to enhance the use, understanding and dissemination of the CERT and presents the meaning and rationale for each item, together with examples of good reporting. The CERT is designed specifically for the reporting of exercise programmes across all evaluative study designs for exercise research. The CERT can be used by authors to structure intervention reports, by reviewers and editors to assess completeness of exercise descriptions and by readers to facilitate the use of the published information. The CERT has the potential to increase clinical uptake of effective exercise programmes, enable research replication, reduce research waste and improve patient outcomes.

Low-back-pain related disability: An integration of psychological risk factors into the stress process model

&NA; The purpose of this study was to verify the usefulness of an adaptation of the stress process model in organizing the psychological variables associated with the development of low‐back‐pain related disability. French‐speaking Canadian workers on compensated sick leave (N = 439) due to recent occupational low back pain (LBP) were evaluated during the sub‐acute stage of LBP (between 30 and 83 days after injury). They were assessed for the following factors: life events, injury‐specific cognitive appraisal, emotional distress, avoidance coping, and functional disability. Confirmatory factor analyses were used to test and modify the measurement model. An important modification in the measurement model was the association of catastrophizing with the emotional distress factor. During the sub‐acute stage, path analyses revealed a satisfactory fit of the following model (the following coefficients are standardized): (a) life events (.30) and cognitive appraisal (.42) explained emotional distress (r2 = .30); (b) emotional distress (.42) and cognitive appraisal (.36) explained the use of avoidance coping (r2 = .45); and (c) emotional distress (.24) and avoidance coping (.56) explained functional disability (r2 = .53). The stress model tested here reaffirms the importance of life events in the development of disability through the more established emotional distress factor. Also, cognitive appraisal appears to have an indirect effect on disability through activity avoidance and distress. This adaptation of the stress model makes it possible to integrate risk factors into a reduced set of meaningful factors and proposes a more general adaptation explanation of disability than the specific fear‐avoidance model.

Consensus on Exercise Reporting Template (CERT): Modified Delphi Study.

Background Exercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice. Objective The aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT). Design and Methods Using the EQUATOR Networks methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used. Results There were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion. Limitations The views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts. Conclusions The CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.

An interdisciplinary clinical practice model for the management of low-back pain in primary care: the CLIP project

BackgroundLow-back pain is responsible for significant disability and costs in industrialized countries. Only a minority of subjects suffering from low-back pain will develop persistent disability. However, this minority is responsible for the majority of costs and has the poorest health outcomes. The objective of the Clinic on Low-back pain in Interdisciplinary Practice (CLIP) project was to develop a primary care interdisciplinary practice model for the clinical management of low-back pain and the prevention of persistent disability.MethodsUsing previously published guidelines, systematic reviews and meta-analyses, a clinical management model for low-back pain was developed by the project team. A structured process facilitating discussions on this model among researchers, stakeholders and clinicians was created. The model was revised following these exchanges, without deviating from the evidence.ResultsA model consisting of nine elements on clinical management of low-back pain and prevention of persistent disability was developed. The models two core elements for the prevention of persistent disability are the following: 1) the evaluation of the prognosis at the fourth week of disability, and of key modifiable barriers to return to usual activities if the prognosis is unfavourable; 2) the evaluation of the patients perceived disability every four weeks, with the evaluation and management of barriers to return to usual activities if perceived disability has not sufficiently improved.ConclusionA primary care interdisciplinary model aimed at improving quality and continuity of care for patients with low-back pain was developed. The effectiveness, efficiency and applicability of the CLIP model in preventing persistent disability in patients suffering from low-back pain should be assessed.

Agreement between a self-administered questionnaire on musculoskeletal disorders of the neck-shoulder region and a physical examination

BackgroundIn epidemiological studies on neck-shoulder disorders, physical examination by health professionals, although more expensive, is usually considered a better method of data collection than self-administered questionnaires on symptoms. However, little is known on the comparison of these two methods of data collection. The agreement between self-administered questionnaires and the physical examination on the presence of neck-shoulders disorders was assessed in the present study.MethodsThis study was conducted among clerical workers using video display units. Prevalent cases were workers for whom neck-shoulder symptoms were present for at least 3 days during the previous 7 days and for whom pain intensity was greater than 50 mm on a 100 mm visual analogue scale. All 85 workers meeting this definition and a random sample of 102 workers who did not meet this definition were selected. Physical examination included measures of active range of motion and musculoskeletal strength. Cohens kappa and global percent agreement were calculated to compare the two methods of data collection. The effect on the agreement of different question and physical examination definitions and the importance of the time interval elapsed between the administrations of the tests were also evaluated.ResultsKappa coefficients ranged from 0.19 to 0.54 depending on the definitions used to ascertain disorders. The agreement was highest when the two instruments were administered 21 days apart or less (Kappa = 0.54, global agreement = 77%). It was not substantially improved by the addition of criteria related to functional limitations or when comparisons were made with alternative physical examination definitions. Pain intensity recorded during physical examination maneuvers was an important element of the agreement between questionnaire and physical examination findings.ConclusionThese results suggest a fair to good agreement between the presence of musculoskeletal disorders ascertained by self-administered questionnaire and physical examination that may reflect differences in the constructs measured. Shorter time lags result in better agreement. Investigators should consider these results before choosing a method to measure the presence of musculoskeletal disorders in the neck-shoulder region.

Psychometric properties of self-reported questionnaires for the evaluation of symptoms and functional limitations in individuals with rotator cuff disorders: a systematic review

Abstract Purpose: To conduct a systematic review of the psychometric properties (reliability, validity and responsiveness) of self-report questionnaires used to assess symptoms and functional limitations of individuals with rotator cuff (RC) disorders. Methods: A systematic search in three databases (Cinahl, Medline and Embase) was conducted. Data extraction and critical methodological appraisal were performed independently by three raters using structured tools, and agreement was achieved by consensus. A descriptive synthesis was performed. Results: One-hundred and twenty articles reporting on 11 questionnaires were included. All questionnaires were highly reliable and responsive to change, and showed construct validity; seven questionnaires also shown known-group validity. The minimal detectable change ranged from 6.4% to 20.8% of total score; only two questionnaires (American Shoulder and Elbow Surgeon questionnaire [ASES] and Upper Limb Functional Index [ULFI]) had a measurement error below 10% of global score. Minimal clinically important differences were established for eight questionnaires, and ranged from 8% to 20% of total score. Conclusion: Overall, included questionnaires showed acceptable psychometric properties for individuals with RC disorders. The ASES and ULFI have the smallest absolute error of measurement, while the Western Ontario RC Index is one of the most responsive questionnaires for individuals suffering from RC disorders. Implications for Rehabilitation All included questionnaires are reliable, valid and responsive for the evaluation of individuals with RC disorders. As all included questionnaires showed good psychometric properties for the targeted population, the choice should be made according to the purpose of the evaluation and to the construct being evaluated by the questionnaire. The WORC, a RC-specific questionnaire, appeared to be more responsive. It should therefore be used to evaluate change in time. If the evaluation is time-limited, shorter questionnaires or short versions should be considered (such as Quick DASH or SST).