Geoff P. Bostick

The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon.

BACKGROUND The optimal rehabilitation protocol after surgical repair of an Achilles tendon rupture has not been well defined. The objective of this randomized study was to compare the effect of early weight-bearing with that of non-weight-bearing on early postoperative recovery following repair of an acutely ruptured Achilles tendon. METHODS Between October 2003 and May 2006, 110 patients with a surgically repaired Achilles tendon rupture were enrolled from one of two major trauma-care tertiary hospitals. All patients were non-weight-bearing for the first two weeks postoperatively. At the two-week postoperative visit, patients were randomized to either weight-bearing or non-weight-bearing for an additional four weeks. Compliance was measured with a pressure sensor in the fixed-hinge ankle-foot orthosis given to each patient. Follow-up assessments were performed at six weeks, three months, and six months postoperatively. The primary outcome was health-related quality of life assessed with use of the RAND 36-Item Health Survey (RAND-36). Secondary outcomes were activity level, calf strength, ankle range of motion, return to sports and work, and complications. RESULTS Ninety-eight patients (89%) completed the six-month follow-up. At six weeks, the weight-bearing group had significantly better scores than the non-weight-bearing group in the RAND-36 domains of physical functioning, social functioning, role-emotional, and vitality scores (p < 0.05). Patients in the weight-bearing group also reported fewer limitations of daily activities at six weeks postoperatively (p < 0.001). At six months, no significant differences between the groups were seen in any outcome, although both groups had poor endurance of the calf musculature. No rerupture occurred in either group. CONCLUSIONS Early weight-bearing after surgical repair of an acute Achilles tendon rupture improves health-related quality of life in the early postoperative period and has no detrimental effect on recovery.

The incidence of Achilles tendon ruptures in Edmonton, Canada.

Background: The incidence of Achilles tendon ruptures specific to the North American population has not been previously reported and current epidemiological data are primarily reported from European communities. The purpose of this study was to determine the incidence of Achilles tendon ruptures in the city of Edmonton, Alberta, Canada, and to compare this data to those reported in European studies. Methods: A retrospective chart review from all five acute care hospitals in Edmonton from 1998 to 2002 (inclusive) were reviewed for Achilles tendon ruptures. Data such as gender, age, side, mechanism of injury, and season of injury were obtained. Results: The incidence of Achilles tendon ruptures ranged from an annual average of 5.5 ruptures to 9.9 ruptures per 100,000 inhabitants with an overall mean of 8.3 ruptures per 100,000 people. There was a statistically significant difference in Achilles tendon ruptures over the last two study years for both genders (women, p < 0.02; men, p < 0.03). The mean age for an Achilles tendon rupture was 40.6 years for men and 44.5 years for women. The Achilles tendon ruptures occurred most frequently in the 30 to 39 and 40 to 49 year old age groups in both men and women, respectively (p < 0.02). Most ruptures occurred in the spring season, but there was no statistical difference in the incidence of Achilles tendon ruptures by season (p > 0.05). Conclusions: The incidence of Achilles tendon ruptures in this community was comparable to those reported in European communities (range 6 to 37 ruptures per 100,000 people), although a bimodal age distribution of rupture previously reported was not observed in this study.

Opioid prescriptions in canadian workers' compensation claimants: prescription trends and associations between early prescription and future recovery.

Study Design. Historical cohort study. Objective. We investigated the prescription of opioids in injured Canadian workers to determine recent trends in use and the association between early prescription and future recovery. Summary of Background Data. Opioid analgesia is effective for reducing chronic nonmalignant pain, and opioid prescriptions for musculoskeletal pain seem to have increased over the past years. However, recent evidence indicates early opioid use may be associated with delayed recovery in patients with back pain. Methods. Data were extracted from the Alberta Workers’ Compensation Board administrative database, and information was obtained on all time loss claims for sprains, strains, fractures, dislocations, amputations, or burns between January 1, 2000 and December 31, 2005. Information on all narcotic prescriptions was obtained along with demographic data and duration of time loss benefits. Injury severity was controlled for via nature of injury coding. Analysis included multivariable logistic and Cox regression. Results. Data were obtained for 137,175 subjects. The majority were males (∼70%) with back sprains (∼35%), and a mean age of 37 years. Between the years 2000 and 2005, all opioid prescriptions within the first year of claim decreased from 11.4% of claimants to 8.3%. Older males with fractures, dislocations, or amputations were more likely to receive narcotics. Claimants receiving early opioid prescriptions experienced delayed suspension of benefits. However, this association was also seen in claimants prescribed early non-narcotic analgesics. Discussion. Prescriptions for opioid analgesia appear to be decreasing within workers’ compensation claimants in Alberta, Canada. As expected, claimants with more severe injuries were more likely to receive opioids. An association was observed between early opioid prescription and delayed recovery, however, this is likely explained by pain severity or other unmeasured confounders.

Factors Associated With Calf Muscle Endurance Recovery 1 Year After Achilles Tendon Rupture Repair

STUDY DESIGN Cohort study. OBJECTIVES To describe calf muscle endurance recovery and to explore factors predictive of poor calf muscle endurance recovery 1 year after surgical repair of an Achilles tendon rupture (ATR). BACKGROUND ATR is a common sports-related injury and is often managed with open surgical repair. After ATR repair most patients return to usual activities 6 months after surgery. However, calf endurance impairment can persist up to 6 years, possibly impacting performance of daily activities and sport. METHODS A secondary analysis of a 73-patient cohort from a randomized controlled trial assessing the effects of early weight bearing after surgical repair of an ATR was performed. Calf muscle endurance recovery was measured by single-heel raises using a customized counting device at 6 months and 1 year postoperatively. Descriptive statistics were used to outline recovery of calf muscle endurance. Physical and patient-reported outcomes were examined for their association with calf-muscle endurance recovery. Multiple linear regression analysis was performed to explore variables associated with recovery of calf endurance 1 year postoperatively. RESULTS Mean recovery of calf muscle endurance was 76% at 1 year. Multivariate regression analysis showed an association of being female, reporting no resting pain at 3 months, and physical functioning and calf endurance at 6 months, with better recovery of calf endurance at 1 year. CONCLUSIONS Calf muscle endurance at 1 year remained impaired in a considerable portion of the sample. Pain, gender, and physical functioning are likely important factors in determining recovery of calf muscle endurance. LEVEL OF EVIDENCE Prognosis, level 2b.J Orthop Sports Phys Ther 2010;40(6):345-351, Epub 15 April 2010. doi:10.2519/jospt.2010.3204.

A population‐based survey of beliefs about neck pain from whiplash injury, work‐related neck pain, and work‐related upper extremity pain

Background: Beliefs about pain conditions appear to influence recovery in a variety of musculoskeletal conditions. Little is known about population beliefs about neck and arm pain.

Predictive capacity of pain beliefs and catastrophizing in Whiplash Associated Disorder

INTRODUCTION Beliefs about pain are known to be important factors in recovery, most notably in LBP. Relatively less is known about the role of pain beliefs in Whiplash Associated Disorder (WAD). The widely advocated cognitive-behavioural approach to pain management necessitates cognitive factors such as pain beliefs be examined, even early after injury. The primary purpose of this study was to explore the predictive capacity of early post-injury pain beliefs and catastrophizing in patients with WAD. METHODS Patients (n=72) undergoing treatment for acute WAD in physical therapy and chiropractic clinics were invited to participate in the study. Research participants were asked to complete measures of beliefs (Survey of Pain Attitudes (SOPA) and Pain Beliefs and Perception Inventory (PBPI)) and catastrophizing (Pain Catastrophizing Scale) at baseline (within 6 weeks of injury), and 3 and 6 months post-injury. In addition, pain severity and self-reported disability using the Whiplash Disability Questionnaire (WDQ) were recorded at each measurement occasion. Baseline belief and catastrophizing scores were examined for their relationship with future pain and disability using multiple linear regression. RESULTS Expectancy beliefs (PBPI Permanence and SOPA Medical Cure) were negatively correlated with pain intensity at 6-months and uniquely accounted for 16% and 14% of explained variance, respectively, after controlling for baseline pain intensity, age, sex and history of WAD. Consistent with previous research, catastrophizing was also found to be predictive of future pain. The amount of unique variance explained by beliefs in the prediction of future disability was modest after controlling for baseline disability, age, sex and history of WAD. DISCUSSION These results suggest that expectancy beliefs are potentially important constructs to include in future explanatory prognosis studies. The Medical Cure and Permanence subscales of the SOPA and PBPI are tools that could be used to measure these expectancy constructs.

Physical Functioning and Opioid use in Patients with Neuropathic Pain

OBJECTIVE To evaluate the association between opioid dosage and ongoing therapy with physical function and disability in patients with neuropathic pain (NeP). DESIGN Secondary analysis of a prospective cohort. SETTING Multicenter clinical NeP registry. SUBJECTS Seven hundred eighty-nine patients treated for various NeP diagnoses. METHODS The following measures were included: dependent variables. 12-month self-reported physical function (pain disability index [PDI] and medical outcomes study short form-12 physical function [PCSS-12]); independent variables: baseline opioid dose (none, ≤200 mg and >200 mg of morphine equivalent), ongoing opioid use; potential confounding variables: age, sex, baseline pain intensity, and psychological distress (profile of mood states). Analysis of covariance models was created to examine the relationship between opioid therapy and both physical functioning outcomes with adjustment for confounding. RESULTS Complete data was available for 535 patients (68%). Compared with the lower and high dose opioid groups, NeP patients not taking opioids had statistically lower disability and higher physical functioning scores, after adjusting for disease severity. Compared with patients prescribed opioid therapy on an ongoing basis, NeP patients who were not prescribed had statistically lower disability and higher physical functioning scores, after adjusting for disease severity. Improvements in disability and physical functioning scores from baseline and 12-months in all groups were modest and may not be clinically significant. CONCLUSIONS Physical functioning and disability did not improve in patients with NeP who were prescribed opioids compared with those who are not prescribed, even after adjusting for disease severity.

Exercise for Prevention of Recurrences of Nonspecific Low Back Pain

Low back pain (LBP) is highly prevalent2 and a common reason for presentation to primary care. 3 The direct and indirect costs associated with this condition are enormous and represent a significant economic burden to health care systems. The prognosis of those with acute LBP is generally positive, with approximately 72% recovering by 1 year. 4 For those who recover, recurrences within the next 12 months following recovery are common. 5,6 It has been well-established that nonspecific LBP is often recurrent and that 24% to 87% of those who recover from an episode of LBP will have a recurrence within 1 year. 5‐8 A theme that is current among clinicians and researchers is the difficulty in defining a recurrence of LBP. Various clinicians and researchers

If they can put a man on the moon, they should be able to fix a neck injury: a mixed-method study characterizing and explaining pain beliefs about WAD.

Purpose: To use quantitative data characterizing whiplash-associated disorder (WAD)-related pain beliefs over time to develop qualitative analysis exploring experiences informing these beliefs. Method: A mixed-method design was used. Quantitative and qualitative data were collected concurrently at baseline and 3 and 6 months postmotor vehicle collision. WAD-related pain beliefs were quantitatively measured in a sample of adults with acute WAD. A subgroup of participants participated in an interview after each survey. Descriptive statistics quantitatively characterized beliefs at each measurement. High or low scores from survey beliefs subscales informed the semistructured interview. The qualitative component explored experiences informing endorsement of beliefs reported on the surveys using a meaning-focused approach. Results: Adjunctive meaning informing endorsement of beliefs related to cure, control, emotions and mystery was achieved. Qualitative analysis revealed a meta-theme labeled restitution, representing a desire to be “fixed”. Stigma also emerged as a potentially important contextual descriptor of WAD meaning. Conclusions: Restitution was the dominant underlying pattern of belief endorsement. While this may be adaptive early after WAD, it is problematic for meaning construction later on. Based on contemporary views on pain, identification of this narrative is important as it represents an incompatibility in the conceptualization of pain between patient and provider. Implications for Rehabilitation The restitution narrative (the desire to be fixed or cured) is common to the formation of meaning throughout all stages of whiplash-associated disorder (WAD) injury, even in people experiencing chronic pain. Viewing WAD through a lens of restitution is adaptive early after injury, but is problematic as WAD persists and/or becomes chronic. Since experts have advocated a shift from treatment to management of persistent pain, patient beliefs about WAD may contradict educational messages delivered by health providers.

An adaptive role for negative expected pain in patients with neuropathic pain.

Objectives:To study the relationship between expected pain and future outcomes along with the moderating effects of expected pain in neuropathic pain patients. Methods:Study participants were recruited for the Canadian Neuropathic Pain Database. To examine the relationship between expected pain and 6-month pain intensity, pain-related disability, and catastrophizing, multiple regressions were performed. These relationships were adjusted for potential confounding (age, sex, baseline pain intensity, and psychological distress). To evaluate the moderating effect of expected pain on the relationship between baseline pain intensity and 6-month outcomes, pain intensity×expected pain interaction terms were created. Results:Complete data for analysis was available for 560 patients (71%). Expected pain was positively correlated with pain intensity and pain-related disability scores at 6 months. The relationship between baseline pain intensity and 6-month catastrophizing scores was moderated by expected pain (however, despite a similar trend, expected pain did not statistically moderate the relationship between baseline pain intensity and 6-month pain intensity or disability). At higher levels of pain, predicted catastrophizing scores were higher for those with low levels of expected pain than those with high levels of expected pain. An opposite relationship was observed for patients with the lower levels of pain. Discussion:In neuropathic pain patients whose pain does not respond to therapy, high levels of expected pain may relate to relatively lower catastrophizing scores by shifting focus away from futile attempts at “curing” pain toward focusing on achievement of more realistic personal goals.