Gunilla Kjellby-Wendt

Early active rehabilitation after surgery for lumbar disc herniation: A prospective, randomized study of psychometric assessment in 50 patients

In a randomized study, using psychometric assessment, we evaluated two training programs before and after surgical treatment of lumbar disc herniation. 26 patients were treated according to an early active training program (treatment group). 24 patients followed a traditional less active training program (control group). Before surgery, the patients filled in the following questionnaires 3 and 12 months after surgery: Multidimensional Pain Inventory (MPI), State and Trait Anxiety Inventory, and Beck Depression Inventory. Pain was assessed by the patients pain drawing and a visual analog scale. Both groups improved as regards pain severity and state of anxiety. The MPI parameter, pain interference, improved more in the early active treatment group than in the control group. This suggests that the early active training program has a positive effect on the way patients cope with pain in their daily lives.

The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain

Pregnancy-related lumbopelvic pain has varying clinical presentations and effects among subgroups. Different lumbopelvic pain subgroups require different specific management approaches which require the differentiation between lumbar and pelvic girdle pain (PGP). Thirty-one consecutive pregnant women with non-specific lumbopelvic pain were evaluated by two examiners and classified into lumbar pain, PGP, or combined pelvic girdle and lumbar pain. A standard history about different positions/activities of daily life such as bending, sitting, standing, walking, and lying, was followed by a standardised mechanical assessment of the lumbar spine (Mechanical Diagnosis and Therapy), including tests of repeated end-range movements to standing and lying, pelvic pain provocation tests (distraction test, posterior pelvic pain provocation test, Gaenslens test, compression test, and sacral thrust) a hip-rotation range-of-motion test, the active straight-leg-raising test, and a neurological examination. Agreement for the three syndromes (lumbar pain, PGP, or combined pelvic girdle and lumbar pain) was 87% (27/31), with a kappa coefficient of 0.79 (95% CI 0.60-0.98). It was possible to perform the classification procedure throughout pregnancy. There was substantial agreement between the two examiners for the classification of non-specific lumbopelvic pain into lumbar pain and PGP in pregnant women.

Physical therapy treatment of back complaints on children and adolescents.

Study Design. A randomized controlled trial was performed. Objectives. To evaluate how 2 different treatment options affect perception of health, pain, and physical functioning over time among children and adolescents with low back pain (LBP). Summary of Background Data. LBP among children and adolescents has increased. The literature shows that children with LBP also suffer from this condition as adults. Thus, it is important to prevent and treat LBP in children and adolescents. Methods. Forty-five children and adolescents were consecutively randomized into one of 2 treatment groups and were studied for 12 weeks. Group 1 was given individualized physical therapy and exercise and a standardized self-training program and back education. Group 2 was given self-training program and back education but no individualized therapy. The children and adolescents were tested before and after the treatment period. Child Health Questionnaire Child Form 87, Roland & Morris Disability Questionnaire, Painometer, Back Saver Sit and Reach, and test of trunk muscle endurance were used to evaluate the interventions. Results. Both groups improved statistically significant in most parameters over time. On comparison between the groups the physical function measured by Roland & Morris Disability Questionnaire and the duration of pain measured by Painometer improved statistically significant in Group 1. Conclusion. An individual assessment by a knowledgeable physiotherapist and an active treatment model improve how children and adolescents experience their back problems with respect to health and physical function, pain, strength, and mobility, regardless of whether treatment consists of a home exercise program with follow-up or home exercise combined with exercise and treatment supervised by a physiotherapist.

Muscle force, balance and falls in muscular impaired individuals with myotonic dystrophy type 1: A five-year prospective cohort study

Individuals with myotonic dystrophy type 1 (DM1) have progressive muscle weakness with gait and balance impairments. We explored prospectively the natural history of muscle force, gait, balance, balance confidence and walking ability in muscular affected individuals with DM1. After five years data from 43 individuals (m/f:18/25) were analysed. All measures of balance showed statistically significant deterioration (p < 0.001) with averaged yearly loss of function by 3-4%. In the group as a whole, loss of muscle force was statistically significant in all lower limb muscles measured after five years: changes relative to baseline force were median -6% to -18%. For males muscle force loss was statistically significant in all leg muscles, but only in hip flexors for women. After five years 100% of the men had fallen during the previous year and 67% three times or more, in contrast only 60% of the women had fallen in the previous year and 36% three times or more. The proportion of individuals seeking medical care the previous year, after falling, was more than doubled after five years, albeit the number of falls had not changed. Awareness of this increased risk of falls is important for caregivers and patients.

The predictive value of psychometric analysis in patients treated by extirpation of lumbar intervertebral disc herniation

The authors studied the predictive value of a psychometric evaluation of 50 patients (14 women, 36 men) with a mean age of 40 years who were treated by extirpation of a lumbar disc herniation. Patient satisfaction was evaluated by an unbiased observer. The Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), and a Pain Visual Analogue Scale (PVAS) were used to assess pain and psychological distress before surgery and 3 and 12 months after surgery. Two years after surgery, 37 patients were contented with the surgical outcome and 10 patients were not. Three patients did not return the questionnaire. Before surgery, the patients who later became discontented were more depressed, more anxious, and experienced more pain. In a discriminant analysis, a combination of BDI, STAI, and PVAS scores correctly classified 78% of the discontented and 76% of the contented patients. The study shows psychometric analysis is a valuable tool for predicting the outcome of surgical treatment for lumbar disc herniation.

Factors of importance for dynamic balance impairment and frequency of falls in individuals with myotonic dystrophy type 1 – A cross-sectional study – Including reference values of Timed Up & Go, 10 m walk and step test

Patients with myotonic dystrophy type 1 suffer from gait difficulties including stumbles and falls. To identify factors of importance for balance impairment and fall-risk a mapping of functional balance was performed, in a cross-sectional study of 51 adults. Walking, balance, falls and muscle force were self-assessed and measured. Reference values of balance were established through measurements of 220 healthy subjects. Falls were more frequently observed in the patients who were more severely affected of muscle weakness than in mildly affected patients, p=0.014. The number of falls showed negative correlation with balance confidence (rs=-0.516, p<0.001). The ankle dorsiflexor force together with the time difference between comfortable and maximum speed in 10m-walk proved to be significant factors for fall frequency. A ten Newton muscle force decrease showed 15% increase in odds ratio for frequent falls. One-second increase in time difference between comfortable and maximum walking speed showed 42% increase in odds ratio for frequent falls. In conclusion, assessing the ankle muscle force and the time difference in different walking speeds is important to detect risk of falling. The activities-specific balance confidence score reflects the consequences of the muscle force decrease. Certain patient strategies to diminish risk of falling could be due.

Results of early active rehabilitation 5-7 years after surgical treatment for lumbar disc herniation.

A prospective and randomized study was conducted of 52 patients who were treated by two home training programs after surgical treatment of lumbar disc herniation. Twenty-six patients followed an early active treatment program, and 26 patients followed a less active training program (control group). Forty-nine patients (82%) answered a questionnaire 5–7 years postoperatively. The reoperation rate was two of 49 patients. None of these patients had followed the early active treatment program. Patients with signs of depression before surgery were not significantly less satisfied with the outcome than patients with no signs of depression before surgery.

Reliability of static and dynamic balance tests in subjects with myotonic dystrophy type 1

The aim of this study was to evaluate test–retest reliability of balance tests and timed walking in individuals with myotonic dystrophy type 1 (DM1). Assessments of static and dynamic balance including timed walking were repeated on three occasions with 1-week intervals. A sample of 10 individuals with functional impairment due to the DM1 disorder participated. The inclusion criteria were: age 20–60; genetically proven DM1 and ability to perform Timed Up&Go (TUG) with or without handheld aids. One Leg and Tandem Stance were assessed as well as Timed 10-m walk (comfortable/maximum pace), TUG, Step Test and Walking in a Figure-of-Eight (Fo8). The analysis of relative reliability comprised the intraclass correlation coefficient (ICC2,1); the analysis of disagreement comprised the standard error of measurement, the repeatability and the measurement error. Mean age of the participants was 42.7 years (± 10.7 years). The ICC was good to high (0.83–0.98) for all tests except Fo8. The analysis of disagreement showed that the dynamic balance tests were more reliable than the static tests. We recommend the use of the dynamic balance tests Step Test and TUG, together with the Timed 10-m walk at maximum pace to evaluate balance performance quantitatively during walking in patients with DM1.

Quantification of mobility impairment and self-assessment of stiffness in patients with myotonia congenita by the physiotherapist

We investigated test-retest reliability and responsiveness in two functional measuring instruments, Timed Up&Go (TUG) and Timed-Stands Test (TST), and in three self-assessment scales, Visual Analogue Scale (VAS), Borgs Category-Ratio Scale (BorgCR10) and Myotonia Behaviour Scale (MBS) when quantifying myotonic stiffness and mobility impairment. These methods were used in the assessment of treatment efficacy of mexiletine. Six male patients with myotonia congenita followed a standardised protocol with time scoring and rest on two occasions, with and without mexiletine. Time scoring of TUG and TST and self-assessments of stiffness were performed. A 14-day stiffness diary was used at home. Timed Up&Go and TST showed very good test-retest agreement (ICC=0.87-0.95) and significant to change (P=0.005 and 0.001, respectively). All self-assessment scales revealed excellent responsiveness and good test-retest reliability. The measurement instruments possess great capacity to detect functional impairment in the myotonia congenita patient group, and sensibility to identify true changes due to treatment. When considering the results, three instruments are favoured; Timed Up&Go and BorgCR10 for short, and MBS for long-term evaluations.

Effects of a balance exercise programme in myotonic dystrophy type 1: A pilot study

Abstract This pilot study aimed to evaluate the effects of balance exercises in adults with classical myotonic dystrophy type 1 (DM1) directly after intervention and at follow-up after 12 weeks. Eleven outpatients (median age 49 years, range 36–60 years) with balance difficulties participating in a 10 week intervention were assessed before, after and at follow-up. The primary outcome measure was balance confidence, measured with the Activities-specific Balance Confidence (ABC) scale. Secondary outcome measures were the Step Test, Timed Up and Go test, Timed 10 m Walk at maximum pace, isometric muscle force in legs and number of falls. The most important findings directly after the intervention were that nine of the 11 patients scored higher on the ABC scale (p = 0.02), and that the number of steps in the Step Test increased in nine of 10 participants. The increased number of steps remained increased at follow-up, but the increased confidence was not maintained for all patients. Timed Up and Go was unchanged but the time to walk 10 m increased. The knee extensor force and number of falls did not show any statistically significant changes. Unexpectedly, all patients deteriorated in the ankle dorsiflexor force (mean –17%) after intervention. The study showed that self-assessed balance confidence is likely to increase following an individualized balance exercise programme in outpatients with DM1.