Hildegunn Lygren

Post‐polio syndrome patients treated with intravenous immunoglobulin: a double‐blinded randomized controlled pilot study

Post‐polio syndrome (PPS) is characterized by new muscle weakness, atrophy, fatigue and pain developing several years after the acute polio. Some studies suggest an ongoing inflammation in the spinal cord in these patients. From this perspective, intravenous immunoglobulin (IvIg) could be a therapeutic option. We performed a double‐blinded randomized controlled pilot study with 20 patients to investigate the possible clinical effects of IvIg in PPS. Twenty patients were randomized to either IvIg 2 g/kg body weight or placebo. Primary endpoints were changes in pain, fatigue and muscle strength 3 months after treatment. Surrogate endpoints were changes in cerebrospinal fluid (CSF) cytokine levels. Secondary endpoints were pain, fatigue and isometric muscle strength after 6 months. Patients receiving IvIg reported a significant improvement in pain during the first 3 months, but no change was noted for subjective fatigue and muscle strength. CSF levels of tumour necrosis factor‐α (TNF‐α) were increased compared with patients with non‐inflammatory neurological disorders. In conclusion, in this small pilot study no effect was seen with IvIg treatment on muscle strength and fatigue, however IvIg treated PPS patients reported significantly less pain 3 months after treatment. TNF‐α was increased in the CSF from PPS patients. The results are promising, but not conclusive because of the low number of patients studied.

Reliability and validity of the back performance scale: observing activity limitation in patients with back pain.

Study Design. A single group design to examine reliability and validity of the Back Performance Scale. Objectives: To examine intertester reliability, test-retest reliability, and concurrent validity of the Back Performance Scale. Summary of Background Data: The Back Performance Scale is a condition-specific performance measure of activity limitation in patients with back pain. It includes five tests of daily activities requiring mobility of the trunk: sock test, pick-up test, roll-up test, fingertip-to-floor test, and lift test. Discriminative ability and responsiveness to important change have previously been demonstrated. Methods. A total of 41 patients with back pain participated in the study. Two physiotherapists examined test performances concurrently, but independently. The patients filled in three questionnaires, two reflecting perceived disability (Der Funktionsfragenbogen Hannover, Roland-Morris Disability Questionnaire) as well as one for fear avoidance of daily activities and work (Fear Avoidance Belief Questionnaire). One physiotherapist retested the patients after 2 to 3 days. Results. Intertester agreement of the Back Performance Scale sum score was very high (intraclass correlation coefficient 2.1): 0.996. Within-patient standard deviation (sw) on the 16-point Back Performance Scale was very low: 0.25. Test-retest reliability was high (intraclass correlation coefficient = 0.91, sw = 1.3). Intertester agreement of the separate tests was also very high, ranging from κ= 0.90–1.00. Test-retest reliability was moderate to high (κ= 0.55–0.83). A high correlation was demonstrated between the Back Performance Scale and the Der Funktionsfragenbogen Hannover: Spearman rho (ρ) = 0.825, P < 0.01. Correlation between the Back Performance Scale and Roland-Morris Disability Questionnaire was moderate: ρ = 0.454, P < 0.01. No correlation was demonstrated between the Back Performance Scale and the Fear Avoidance Belief Questionnaire. Conclusion. The Back Performance Scale appears to be a reliable and valid outcome measure of activity limitation.

Test-retest reliability of the progressive isoinertial lifting evaluation (PILE)

Study Design. A repeated measures single group design. Objectives. To investigate test-retest reliability of Progressive Isoinertial Lifting Evaluation on patients with long lasting musculoskeletal problems related to the lumbar spine. Summary of Background Data. Test-retest reliability has been satisfactory in healthy men. Test-retest reliability for clinical populations has not been reported. Methods. A total of 31 patients (17 women and 14 men) with long lasting low back pain participated in the study. The patients were tested twice at an interval of 2 days and at the same time of the day. The heaviest load that the patient could lift 4 times was used as outcome measure. Results. The error of measurement indicates that the true result in 95% of cases will be within ±4.5 kg from the measured value, while the difference between 2 measurements in 95% of cases will be less than 6.4 kg. Intra-class correlation (1,1) was 0.91. Conclusions. Relative test-retest reliability was high assessed by intra-class correlation, but absolute measurement variability reported as the smallest detectable difference has relevance for the interpretation of clinical test results and should also be considered.

Responsiveness to Change of 10 Physical Tests Used for Patients With Back Pain

Background Few studies have examined the responsiveness of physical tests. Objective The purpose of this study was to explore the responsiveness of 10 physical tests used for patients with back pain in order to illuminate the significance of changes in scores. Design Cross-sectional and longitudinal designs within a prospective cohort study were applied. Methods Distribution-based and anchor-based methods were used. Ninety-eight patients (18–65 years of age) with long-lasting back pain were recruited consecutively at an outpatient spine clinic. Measurements The participants were assessed using 10 physical tests and 2 questionnaires (Hannover Functional Ability Questionnaire and Roland-Morris Disability Questionnaire) at inclusion and after rehabilitation. Six predefined hypotheses for each test were examined regarding the association between changes in scores on the physical tests and the self-report measures of functioning and regarding the relationship of changes in scores on the physical tests and external anchors of important change. Results Five physical tests demonstrated responsiveness by both distribution-based and anchor-based methods: spondylometry, lateral flexion test, fingertip-to-floor test, lift test, and Back Performance Scale (4 hypotheses confirmed). The minimal important change values were all within the range of the smallest detectable change for individual patients. Responsiveness by distribution-based methods only (3 hypotheses confirmed) was shown for the Biering-Sørensen test and the loaded reach test, whereas little evidence of responsiveness (1 hypothesis confirmed) was shown for the Global Physiotherapy Examination flexibility subscale, the Progressive Isoinertial Lifting Evaluation, and the 15-m (50-ft) walk test. Limitations The smallest detectable change values were examined in a small sample of patients and need further exploration. Conclusions Responsiveness varied among the 10 physical tests.

Validation of the Norwegian version ofHannover Functional Ability Questionnaire.

Study Design. Cross-sectional and longitudinal designs within a prospective cohort study. Objective. Translation of Hannover Functional Ability Questionnaire (FFbH-R) into Norwegian and examination of its factor structure, internal consistency, reproducibility, construct validity, and responsiveness in patients with long-lasting back pain. Summary of Background Data. Several condition-specific instruments have been developed to evaluate functional status in low back pain, but FFbH-R was the only instrument found to solely measure perceived capability of performing daily activities. Methods. Recommended guidelines for translation of questionnaires and quality criteria for validation were followed. A total of 111 patients (aged 18–65 years) with long-lasting back pain were consecutively recruited from an outpatient spine clinic. Two additional samples of patients with long-lasting back pain were added into the exploratory factor analysis, giving a total number of 224 patients. Predefined hypotheses regarding construct and longitudinal validity (responsiveness) were examined. Results. Factor analysis indicated that 2 items should be removed, resulting in a 3-factor solution as the best fit. The factors were related to flexibility, dynamic strength, and posture endurance. Satisfactory internal consistency and reproducibility were demonstrated for the total and subscales of the Norwegian version of FFbH-R. Most of the predefined hypothesis regarding construct and longitudinal validity were confirmed, and discriminate ability was shown. Minor floor and ceiling effects were demonstrated. Conclusion. Psychometric properties of the Norwegian version of FFbH-R were satisfactory in patients with long-lasting back pain, but the dynamic strength and posture endurance subscales might be complemented with additional items.

Reconsidering the Roland-Morris Disability Questionnaire: time for a multidimensional framework?

Study Design. Cross-sectional design. Objective. To explore (1) the factor structure of the Roland-Morris Disability Questionnaire (RMDQ), (2) whether there is a dominant factor, and (3) whether the potential factors are unique predictors of other aspects related to back pain. Summary of Background Data. The RMDQ is one of the most recommended back-specific questionnaires assessing disability. The RMDQ is scored as a unidimensional scale summarizing answers to all 24 questions (Yes/No) regarding daily life functioning. However, there are indications that the scale is multidimensional. Methods. Patients (n = 457; age, 18–60 yr) with 8 to 12 weeks of back pain filled in questionnaires assessing subjective health complaints, emotional distress, instrumental and emotion-focused coping, and fear voidance behavior at baseline. A total of 371 patients (81.7%) filled in the RMDQ. Exploratory factor analysis was used to examine the factor structure of RMDQ items. Multiple regression analyses were used to assess whether the derived factors predicted relevant problems in back pain differently. Results. Exploratory factor analysis showed indices of model fit for a 3-factor solution after removing 2 items because of low prevalence (19 and 24). Two items were removed because of cross-loadings and low loadings (2 and 22). No support for a dominant factor was found as the 3 factors were only moderately correlated (r = 0.34–0.40), and the ratio between the first and second eigenvalue was 2.6, not supporting essential unidimensionality. “Symptoms” were the factor that most strongly predicted subjective health complaints, whereas “avoidance of activity and participation” predicted fear avoidance behavior, instrumental and emotional coping. “Limitation in daily activities” did not predict any of these variables. Conclusion. The main findings of our study are that the RMDQ consists of 3 independent factors, and not 1 dominant factor as suggested previously. We think the time is now ripe to start treating and scoring the RMDQ as a multidimensional scale. Level of Evidence: N/A

Impact of a Multifaceted and Clinically Integrated Training Program in Evidence-Based Practice on Knowledge, Skills, Beliefs and Behaviour among Clinical Instructors in Physiotherapy: A Non-Randomized Controlled Study.

Background and Purpose Physiotherapists practicing at clinical placement sites assigned the role as clinical instructors (CIs), are responsible for supervising physiotherapy students. For CIs to role model evidence-based practice (EBP) they need EBP competence. The aim of this study was to assess the short and long term impact of a six-month multifaceted and clinically integrated training program in EBP on the knowledge, skills, beliefs and behaviour of CIs supervising physiotherapy students. Methods We invited 37 CIs to participate in this non-randomized controlled study. Three self-administered questionnaires were used pre- and post-intervention, and at six-month follow-up: 1) The Adapted Fresno test (AFT), 2) the EBP Belief Scale and 3) the EBP Implementation Scale. The analysis approach was linear regression modeling using Generalized Estimating Equations. Results In total, 29 CIs agreed to participate in the study: 14 were invited to participate in the intervention group and 15 were invited to participate in the control group. One in the intervention group and five in the control group were lost to follow-up. At follow-up, the group difference was statistically significant for the AFT (mean difference = 37, 95% CI (15.9 -58.1), p<0.001) and the EBP Beliefs scale (mean difference = 8.1, 95% CI (3.1 -13.2), p = 0.002), but not for the EBP Implementation scale (mean difference = 1.8. 95% CI (-4.5-8.1), p = 0.574). Comparing measurements over time, we found a statistically significant increase in mean scores related to all outcome measures for the intervention group only. Conclusions A multifaceted and clinically integrated training program in EBP was successful in improving EBP knowledge, skills and beliefs among CIs. Future studies need to ensure long-term EBP behaviour change, in addition to assessing CIs’ abilities to apply EBP knowledge and skills when supervising students.

Basic Body Awareness Therapy and patient education in hip osteoarthritis: a multiple case study

Abstract International guidelines recommend exercise and patient education (PE) in hip osteoarthritis. However, we need more in-depth evidence regarding the effect of different exercise modalities. The aim of this study was to examine short- and long-term outcomes of PE and Basic Body Awareness Therapy (BBAT). Seven patients (five men, two women) with moderate to severe osteoarthritis were recruited. Pain, function and quality of life were assessed at baseline and after 4 and 10 months, pain during walking being the main outcome. PE, aiming for patients’ empowerment through information and counselling, was given in a 2 h group setting. BBAT, focusing on promoting movement quality and awareness in a variety of daily movements, was given weekly in groups over 12 weeks. Five patients participated in PE and BBAT, two in PE only. After 4 months all reported improvement. Less pain during walking was found in four patients, and after 10 months in three patients (one PE, two PE and BBAT, two missing). One patient (PE) reported being unchanged and one (PE and BBAT) worse and motivated for surgery, both with 0 mm joint space. BBAT and PE may be beneficial in hip osteoarthritis, but the supplementary effect of BBAT must be further examined.