Francesca Bonetti

An updated overview of clinical guidelines for chronic low back pain management in primary care

OBJECTIVES In the past decade many countries around the world have produced clinical practice guidelines to assist practitioners in providing a care that is aligned with the best evidence. The aim of this study was to present and compare the most established evidence-based recommendations for the management of chronic nonspecific low back pain in primary care derived from current high-quality international guidelines. METHODS Guidelines published or updated since 2002 were selected by searching PubMed, CINAHL, EMBASE, guidelines databases, and the World Wide Web. The methodological quality of the guidelines was assessed by three authors independently, using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Guideline recommendations were synthesized into diagnostic and therapeutic approaches that were supported by strong, moderate or weak evidence. RESULTS Thirteen guidelines were included. In general, the quality was satisfactory. Guidelines had highest scores on clarity and presentation and scope and purpose domains, and lowest scores on applicability. There was a strong consensus among all the guidelines particularly regarding the use of diagnostic triage and the assessment of prognostic factors. Consistent therapeutic recommendations were information, exercise therapy, multidisciplinary treatment, and combined physical and psychological interventions. CONCLUSION Compared to previous assessments, the average quality of the guidelines dealing with chronic low back pain has improved. Furthermore, all guidelines are increasingly aligning in providing therapeutic recommendations that are clearly differentiated from those formulated for acute pain. However, there is still a need for improving quality and generating new evidence for this particular condition.

Effectiveness of a 'Global Postural Reeducation' program for persistent low back pain: a non-randomized controlled trial.

BackgroundThe aim of this non-randomized controlled trial was to evaluate the effectiveness of a Global Postural Reeducation (GPR) program as compared to a Stabilization Exercise (SE) program in subjects with persistent low back pain (LBP) at short- and mid-term follow-up (ie. 3 and 6 months).MethodsAccording to inclusion and exclusion criteria, 100 patients with a primary complaint of persistent LBP were enrolled in the study: 50 were allocated to the GPR group and 50 to the SE group. Primary outcome measures were Roland and Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI). Secondary outcome measures were lumbar Visual Analogue Scale (VAS) and Fingertip-to-floor test (FFT). Data were collected at baseline and at 3/6 months by health care professionals unaware of the study. An intention to treat approach was used to analyze participants according to the group to which they were originally assigned.ResultsOf the 100 patients initially included in the study, 78 patients completed the study: 42 in the GPR group and 36 in the SE group. At baseline, the two groups did not differ significantly with respect to gender, age, BMI and outcome measures. Comparing the differences between groups at short- and mid-term follow-up, the GPR group revealed a significant reduction (from baseline) in all outcome measures with respect to the SE group.The ordered logistic regression model showed an increased likelihood of definitive improvement (reduction from baseline of at least 30% in RMDQ and VAS scores) for the GPR group compared to the SE group (OR 3.9, 95% CI 2.7 to 5.7).ConclusionsOur findings suggest that a GPR intervention in subjects with persistent LBP induces a greater improvement on pain and disability as compared to a SE program. These results must be confirmed by further studies with higher methodological standards, including randomization, larger sample size, longer follow-up and subgrouping of the LBP subjects.Trial registrationNCT00789204

The Italian version of the Fear-Avoidance Beliefs Questionnaire (FABQ-I): cross-cultural adaptation, factor analysis, reliability, validity, and sensitivity to change.

Study Design. Evaluation of the psychometric properties of a translated and culturally adapted questionnaire. Objective. Translating, culturally adapting, and validating the Italian version of the Fear-Avoidance Beliefs Questionnaire (FABQ-I) to allow its use with Italian-speaking patients with low-back pain (LBP). Summary of Background Data. Growing attention is being given to standardized outcome measures to improve interventions for LBP. A translated form of the FABQ has never been validated in Italian patients with LBP. Methods. The FABQ-I questionnaire was developed by means of forward-backward translation, a final review by an expert committee, and a test of the prefinal version to establish its correspondence with the original English version. The psychometric testing included factor analysis, reliability by internal consistency (Cronbach &agr;) and test-retest reliability (intraclass coefficient correlation), convergent validity by comparing FABQ-I with the Italian version of the Tampa Scale of Kinesiophobia (TSK-I), and discriminant validity by comparing FABQ-I with a visual analogue scale, the Roland Morris Disability Questionnaire, and the Hospital Anxiety and Depression Scale (Pearson correlation). Results. It took 4 months to develop a shared version of the FABQ-I. The questionnaire was administered to 180 subjects and proved to be acceptable. Factor analysis revealed a 2-factor, 12-item solution (57% of explained variance). The questionnaire showed good internal consistency (&agr; = 0.822) and high test-retest reliability (intraclass coefficient correlation = 0.869). Convergent validity showed a moderate correlation with TSK-I (r = 0.440), and discriminant validity showed moderate-poor correlations with a visual analogue scale (r = 0.335), Roland Morris Disability Questionnaire (r = 0.414), and Hospital Anxiety and Depression Scale (r = 0.258 for the Anxiety score and r = 0.246 for the Depression score). The results of the psychometric analyses of the subscales were similar to those of the scale as a whole. Conclusion. The FABQ outcome measure was successfully translated into Italian and proved to have a good factorial structure and psychometric properties that replicated the results of other existing versions. Its use is recommended for research purposes.

Cross-cultural adaptation and validation of the Physical Therapy Outpatient Satisfaction Survey in an Italian musculoskeletal population

BackgroundAlthough patient satisfaction is a relevant outcome measure for health care providers, few satisfaction questionnaires have been generally available to physical therapists or have been validated in an Italian population for use in the outpatient setting. The aim of this study was to translate, culturally adapt, and validate the Italian version of the Physical Therapy Outpatient Satisfaction Survey (PTOPS).MethodsThe Italian version of the PTOPS (PTOPS-I) was developed through forward-backward translation, review, and field-testing a pre-final version. The reliability of the final questionnaire was measured by internal consistency and test-retest stability at 7 days. Factor analysis was also used to explore construct validity. Concurrent validity was measured by comparing PTOPS-I with a 5-point Likert-type scale measure assessing the Global Perceived Effect (GPE) of the treatment and with a Visual Analogue Scale (VAS).Results354 outpatients completed the PTOPS-I, and 56 took the re-test. The internal consistency (Cronbach’s alpha) of the original domains (Enhancers, Detractors, Location, and Cost) was 0.758 for Enhancers, 0.847 for Detractors, 0.885 for Location, and 0.706 for Cost. The test-retest stability (Intra-class Correlation Coefficients) was 0.769 for Enhancers, 0.893 for Detractors, 0.862 for Location, and 0.862 for Cost. The factor analysis of the Italian version revealed a structure into four domains, named Depersonalization, Inaccessibility, Ambience, and Cost. Concurrent validity with GPE was significantly demonstrated for all domains except Inaccessibility. Irrelevant or non-significant correlations were observed with VAS.ConclusionThe PTOPS-I showed good psychometric properties. Its use can be suggested for Italian-speaking outpatients who receive physical therapy.

Italian Version of the Physical Therapy Patient Satisfaction Questionnaire: Cross-Cultural Adaptation and Psychometric Properties

Background Patient satisfaction is an important measure for evaluating interventions in health care. No patient satisfaction questionnaire for physical therapy treatment has been validated to date for use in an Italian outpatient population. Objective The aim of this study was to translate, culturally adapt, and validate the Italian version of the Physical Therapy Patient Satisfaction Questionnaire (PTPSQ-I). Design A measurement study was conducted. Methods The PTPSQ-I was developed through forward-backward translation, final review, and pre-final version. An acceptability analysis was first conducted. Reliability was measured by internal consistency (Cronbach α), and a factor analysis was applied to investigate the internal structure. Divergent validity was measured by comparing the PTPSQ-I with a visual analog scale (VAS) and with a 5-point Likert-type scale evaluating the global perceived effect (GPE) for the physical therapy treatment. Results The process for developing the PTPSQ-I required 3 months using data on 315 outpatients. Based on our initial analyses, 5 items were deleted from the PTPSQ-I, which was renamed the PTPSQ-I(15). The PTPSQ-I(15) showed high internal consistency (α=.905). Divergent validity was moderate for the GPE (r=.33) but not significant for the VAS (r=−.07). A factor analysis revealed evidence for a 2-factor structure related to perceived “Overall Experience” and “Professional Impression” that explained 62% of the total variance. A third factor, “Efficiency and Convenience,” brought explained total variance to near 70%. Limitations It may be necessary to add items to the PTPSQ-I(15) to assess other dimensions not currently represented by these 15 items. Conclusion The PTPSQ-I(15) showed good psychometric properties, and its use can be recommended with Italian-speaking outpatient populations.

RASCH ANALYSIS OF THE NECK BOURNEMOUTH QUESTIONNAIRE TO MEASURE DISABILITY RELATED TO CHRONIC NECK PAIN

OBJECTIVE To determine the psychometric properties of the Neck Bournemouth Questionnaire in patients with chronic neck pain, using Rasch analysis. METHODS A sample of 161 subjects with chronic neck pain was assessed with the Neck Bournemouth Questionnaire. Before performing Rasch analysis, we examined the structure of the scale with factor analysis. The goodness-of-fit of the data to the model, thresholds ordering, unidimensionality, local independence of the items, differential item functioning, person separation index, and mean persons location were assessed. RESULTS Both exploratory and confirmatory factor analyses supported the presence of 2 factors. Only Factor 1 needed a modification (item 7 removal) in order to achieve the fit to the Rasch model (χ2 = 10.65, df 8, p = 0.22). The person separation index was 0.80 and the mean location of persons 0.48 (standard deviation (SD) 1.02). Factor 2 (items 4 and 5) fitted the model without modifications (χ2 = 3.86, df 4, p = 0.42). Its person separation index and mean persons location were, respectively, 0.77 and -0.71 (SD 1.57). CONCLUSION The Neck Bournemouth Questionnaire with the purposed modification may provide useful clinical profiles and change scores of subjects with chronic neck pain for research purposes.

Rasch analysis of the Italian version of fear avoidance beliefs questionnaire (FABQ-I)

Abstract Purpose: To perform a Rasch analysis (RA) of the Fear Avoidance Beliefs questionnaire (FABQ-I) in a sample of chronic non-specific low back pain (CLBP) patients. The RA is expected to provide information about the internal construct validity and all the single items consistency of the FABQ-I and then contributing to the knowledge about the questionnaire’s clinimetric properties. Methods: One hundred and fifty subjects with CLBP were enrolled into the study. The FABQ-I have been studied by means of RA. The sample size needed to obtain stable person, item and rating-scale calibrations for use with the Rasch model was based on the level of error expected in the measure. Results: RA did not support the total scale as an unidimensional measure of Fear Avodiance Beliefs. Also the analysis of the Physical Activity (PA) and Word (WO) subscales as well as the attempts of manipulation failed in achieving an acceptable fit to the Rasch model. Conclusion: FABQ-I may be considered to reflect a multiple psychological constructs describing scale. The raw score of the FABQ-I and changes in scores must be interpreted with caution because as a general measure of fear avoid beliefs was not supported. Implication for Rehabilitation Fear avoidance beliefs questionnaire (FABQ-I) as a whole, as well as the PA and WO subscales does not fit Rasch model thus indicating a “Fear Avoidance” represent a multidimensional construct. Practitioners should be aware that FABQ-I need to be used with caution in clinical settings. The score of different items should not be summed in order to obtain an “overall score of Fear Avoidance Beliefs”. Every item of the FABQ-I potentially defines its own dimension. Changes in scores must be interpreted with caution because FABQ-I as a general measure of fear avoid beliefs was not supported, also the ability to distinguish between distinct levels of the underlying trait is poor. Caution: This study was conducted on a sample of Chronic Low Back Pain patients; thus, the results might not be generalized on patients with other pathologies/conditions.

The Italian version of the Physical Therapy Patient Satisfaction Questionnaire - [PTPSQ-I(15)]: psychometric properties in a sample of inpatients

BackgroundIn a previous study we described the translation, cultural adaptation, and validation of the Italian version of the PTPSQ [PTPSQ-I(15)] in outpatients. To the authors’ knowledge, the PTPSQ was never studied in a hospital setting.The aims of this study were: (1) to establish the psychometric properties of the Physical Therapy Patient Satisfaction Questionnaire [PTPSQ- I(15)] in a sample of Italian inpatients, and (2) to investigate the relationships between the characteristics of patients and physical therapists and the indicators of satisfaction.MethodsThe PTPSQ-I(15) was administered to inpatients in a Physical Medicine and Rehabilitation Unit. Reliability of the PTPSQ-I(15) was measured by internal consistency (Cronbach’s α) and test-retest stability (ICC 3,1). The internal structure was investigated by factor analysis. Divergent validity was measured by comparing the PTPSQ-I(15) with a Visual Analogue Scale (VAS) for pain and with a 5-point Likert-type scale evaluating the Global Perceived Effect (GPE) of the physical therapy treatment.ResultsThe PTPSQ-I(15) was administered to 148 inpatients, and 73 completed a second administration. The PTPSQ-I(15) showed high internal consistency (α = 0.949) and test-retest stability (ICC = 0.996). Divergent validity was moderate for the GPE (r = − 0.502, P < 0.001) and strong for the VAS (r = −0.17, P = 0.07). Factor analysis showed a one-factor structure.ConclusionsThe administration of PTPSQ-I(15) to inpatients demonstrated strong psychometric properties and its use can be recommended with Italian-speaking population. Further studies are suggested on the concurrent validity and on the psychometric properties of the PTPSQ-I(15) in different hospital settings or with other pathological conditions.