Ida Løchting

Cross-cultural adaptation and validation of the Norwegian pain catastrophizing scale in patients with low back pain.

BackgroundPain catastrophizing has been found to be an important predictor of disability and days lost from work in patients with low back pain. The most commonly used outcome measure to identify pain catastrophizing is the Pain Catastrophizing Scale (PCS). To enable the use of the PCS in clinical settings and research in Norwegian speaking patients, the PCS had to be translated. The purpose of this study was therefore to translate and cross-culturally adapt the PCS into Norwegian and to test internal consistency, construct validity and reproducibility of the PCS.MethodsThe PCS was translated before it was tested for psychometric properties. Patients with subacute or chronic non-specific low back pain aged 18 years or more were recruited from primary and secondary care. Validity of the PCS was assessed by evaluating data quality (missing, floor and ceiling effects), principal components analysis, internal consistency (Cronbach’s alpha), and construct validity (Spearman’s rho). Reproducibility analyses included standard error of measurement, minimum detectable change, limits of agreement, and intraclass correlation coefficients.ResultsA total of 38 men and 52 women (n = 90), with a mean (SD) age of 47.6 (11.7) years, were included for baseline testing. A subgroup of 61 patients was included for test-retest assessments. The Norwegian PCS was easy-to-comprehend. The principal components analysis supported a three-factor structure, internal consistency was satisfactory for the PCS total score (α 0.90) and the subscales rumination (α 0.83) and helplessness (α 0.86), but not for the subscale magnification (α 0.53). In total, 86% of the correlation analyses were in accordance with predefined hypothesis. The reliability analyses showed intraclass correlation coefficients of 0.74 − 0.87 for the PCS total score and subscales. The PCS total score (range 0–52 points) showed a standard error of measurement of 4.6 points and a 95% minimum detectable change estimate of 12.8 points.ConclusionsThe Norwegian PCS total score showed acceptable psychometric properties in terms of comprehensibility, consistency, construct validity, and reproducibility when applied to patients with subacute or chronic LBP from different clinical settings. Our study support the use of the PCS total score for clinical or research purposes identifying or evaluating pain catastrophizing.

What's in Team Rehabilitation Care After Arthroplasty for Osteoarthritis? Results From a Multicenter, Longitudinal Study Assessing Structure, Process, and Outcome

Background Clinical course and outcome connected to rehabilitation after hip or knee arthroplasty have been studied extensively, but few studies have assessed the content of team rehabilitation care for these patients. Objective The purpose of this study was to provide a thorough description of the structure, process, and outcome of team rehabilitation care for patients with hip or knee arthroplasty for osteoarthritis. Design This was a multicenter, longitudinal observational study. Methods Patients (N=183) from 6 rehabilitation centers in Norway who were undergoing inpatient rehabilitation following hip or knee arthroplasty were included in the study. Structure and process components were recorded by participants and health care professionals in a patient diary. Participants also completed questionnaires regarding their experiences during their rehabilitation stay and recorded data for outcome measures at admission, at discharge, and 6 months after discharge. The main outcome measures were pain intensity and physical function, as assessed with the physical function scale of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Results Data were complete for 172 participants (94%) at discharge and for 148 patients (81%) at the 6-month follow-up. Health care professionals, physical therapists, nurses, and physicians were most often involved in team care. Occupational therapists, social workers, and psychologists were seldom part of the rehabilitation team. Exercises provided by physical therapists were the most common treatment modality. Patient education, massage, and manual therapy also frequently were provided. The participants were very satisfied with their care and its organization, information, and communication and with the availability of health care professionals. They were moderately satisfied with the social environment of the rehabilitation setting. The participants had large improvements in the outcome measures during the rehabilitation stay and at the 6-month follow-up. Limitations For typical physical therapy modalities such as exercises, electrotherapy, and acupuncture, there are limited descriptions and assessments of treatment doses. Conclusions Current team rehabilitation care involves a traditional team with physical therapists, nurses, and physicians. Several types of treatment modalities are used, with greatest emphasis on physical training. This detailed description of current team rehabilitation practice might help clinicians and researchers in planning clinical trials within a rehabilitation setting, as well as in improving rehabilitation practice.

Psychometric properties of the Norwegian version of the Patient Generated Index in patients with rheumatic diseases participating in rehabilitation or self-management programmes

OBJECTIVE In rehabilitation, treatment is individually tailored to each patients goals. Individualized instruments allow patients to choose domains that they consider important, which may make them particularly appropriate as evaluative tools in this setting. We aimed to evaluate the psychometric properties of the Norwegian version of the patient generated index (PGI) in patients with rheumatic diseases participating in inpatient rehabilitation or self-management programmes. METHODS Patients completed the PGI together with other outcome measures at arrival and 5 and 52 weeks after arrival. The PGI was assessed for data quality by completion rates, reliability by the intraclass correlation coefficient (ICC), agreement by standard error of measurement (SEM) and smallest detectable change (SDC). Construct validity was assessed by testing a priori hypotheses regarding correlation between PGI scores and other outcome measures. Responsiveness was assessed by an a priori hypothesis regarding the correlation of different change scores and standardized response means (SRMs). RESULTS A total of 145 patients participated and 118 (81%) completed the PGI correctly. The ICC was 0.87, SEM 7.25 and SDC 20.10. Ninety-three per cent of the hypotheses of correlation were confirmed in tests for construct validity. Responsiveness was confirmed in 53% and 71% of hypotheses tested at 5 and 52 weeks. SRMs were 0.2 and 0.4, respectively. CONCLUSION The results support the validity, reliability and responsiveness of the Norwegian version of the PGI in patients with rheumatic diseases and its application as an outcome measure in rehabilitation or self-management programmes. Further research is needed to improve completion rates for the PGI.

Does the content really matter? A study comparing structure, process, and outcome of team rehabilitation for patients with inflammatory arthritis in two different clinical settings

Objectives: To provide a thorough description of team rehabilitation care and compare the structure, process, and outcomes in two specialized arthritis rehabilitation settings. Methods: Patients with inflammatory arthritis scheduled for inpatient rehabilitation in seven specialized rehabilitation centres and three rheumatology hospital departments in Norway were included consecutively in a prospective cohort study. Patients completed questionnaires at admission, at discharge, and at a 6-month follow-up, and kept a diary regarding structure and process variables during the rehabilitation stay. Results: Eighty patients in rehabilitation centres and 73 in hospital departments were included and 80% responded to the 6-month follow-up questionnaire. The two clinical settings differed significantly with regard to structure variables such as cost, referral of patients, length of stay, and number of health professionals involved, and most process variables reflecting treatment modalities. The most remarkable difference was in the amount of individual intervention compared with group intervention. Despite significant improvements in most outcomes at discharge, the scores deteriorated towards baseline level 6 months later. There was a trend towards more significant improvement during rehabilitation for patients at rehabilitation centres whereas patients at hospitals had more prolonged improvement. Conclusions: Team rehabilitation for inflammatory arthritis in two different clinical settings differed across most variables for structure and process, but few significant differences in outcome were found. Considering the substantial differences in cost, there is an urgent need for consensus concerning which patients should receive rehabilitation in which setting. Future research on the development and evaluation of methods for prolonging the beneficial effects of rehabilitation is needed.

The COPE LBP trial: Cognitive Patient Education for Low Back Pain - a cluster randomized controlled trial in primary care

BackgroundNon-specific low back pain (LBP) is usually self-limiting within 4-6 weeks. Longstanding pain and disability are not predictable from clinical signs or pathoanatomical findings. Pain cognition and physical performance have been shown to improve patients with chronic LBP following neurophysiological education. The primary aim of this study is to evaluate whether a specific cognitive based education programme for patients with LBP in primary care is more effective than normal care in terms of increased function. The secondary aims of the study are to evaluate whether this intervention also results in earlier return to work, decreased pain, increased patient satisfaction, increased quality-of-life, and cost utility.Methods/DesignCluster randomised controlled trial with 20 general practitioners and 20 physiotherapists in primary care as the unit of randomisation. Each practitioner will recruit up to 10 patients, aged 20 to 55 years, with non-specific sub-acute/chronic LBP of more than four weeks but less than 1 years duration. Practitioners in the intervention arm will provide cognitive patient education intervention in up to four weekly sessions, each lasting 30 minutes. Practitioners in the control arm will provide normal treatment, but have to make four appointments for the patients. Patients, outcome assessors, and study statistician will be blinded to group allocation.DiscussionWe present the rationale and design of an ongoing RCT study that potentially offers an easily implemented treatment strategy for LBP patients in primary care. The results will be available in 2012.Trial registrationISRCTN04323845

Evaluation of the Brief Illness Perception Questionnaire in Sub-Acute and Chronic Low Back Pain Patients: Data Quality, Reliability and Validity

Background Illness perceptions have received increasing attention in the treatment of a range of illnesses and medical conditions, however, the instruments available have not been evaluated on sub-acute and chronic low back pain patients. This study aims to evaluate the Brief IPQ in the prevailing patient group. Methods The Brief IPQ was administered to 90 patients attending care in Norway and evaluated for data quality, reliability and validity. The questionnaire was re-administered to 61 patients within a week for re-test purposes. The evaluation followed COSMIN recommendations for measurement properties. Results Item missing data ranged from 0% to 6.7%. Item-total correlation ranged from 0.12 to 0.67. Cronbach’s alpha was 0.72 for the Brief IPQ scale. Test-retest intra class correlation (ICC) values were 0.86 for the scale and ranged from 0.64 to 0.88 for the individual items. The standard error of measurement (SEM) for the Brief IPQ scale (0- 10) was 0.63 and the minimal detectable change (MDC) was 1.75. The MDC for single items (0-10) ranged from 3.16 to 4.40. Brief IPQ scale scores were approximately normally distributed and had small to moderate correlations with the reference scales supporting the hypotheses, however, the hypothesis were only partly supported on single item level. Conclusions The Brief IPQ can be applied as a concise instrument for assessing illness perceptions of patients with sub-acute and chronic low back pain. The Brief IPQ scale has evidence for reliability and validity however the evidence was less satisfactory at the item level.

Cognitive Patient Education for Low Back Pain in Primary Care: A Cluster Randomized Controlled Trial and Cost-Effectiveness Analysis.

Study Design. A pragmatic cluster randomized controlled trial in primary care. Objective. The aim of this study was to estimate the clinical effectiveness and cost-effectiveness of a cognitive-based education program on patients with subacute or chronic low back pain (LBP) in primary care, compared to usual treatment, provided by general practitioners (GP) and physiotherapists (PT). Summary of Background Data. Patient education has been reported to have a favorable effect on patients with chronic musculoskeletal disorders. In this study, an “Explain Pain” model was adapted to fit into an ordinary clinical setting in Norwegian primary care. Methods. Sixteen GPs and 20 PTs participated in the study and a total of 216 patients were recruited. The GPs and PTs were randomly assigned to provide either a cognitive patient education or usual treatment. All patients in both groups were provided with four consultations of 30 min with their provider during the study. In the intervention group the patients were educated according to a specific manual written for the purpose of this study. Results. Eighty-one percent responded at 4-week, and 68% at the 12-month follow-up. There was a substantial improvement in function, pain, and sick leave in both groups. After 4 weeks the intervention group scored 0.51 RMDQ points lower than the control group (Beta –0.506 [95% CI –1.76–0.75]). After 12 months the intervention group scored 0.66 RMDQ points higher than the control group (Beta 0.66 [95% CI −0.56–1.88]). There was no significant difference in QALYs in the two treatment groups; the estimated difference was 0.005 (−0.016–0.027) in favor of the intervention. Conclusion. This study showed no clinical or health economic benefits as a result of adding a cognitive education program to usual treatment for patients with subacute and chronic LBP. Potential weaknesses such as a long recruiting period and potentially low compliance with the cognitive intervention warrant a careful interpretation of the results. Level of Evidence: 3

Individualized quality of life in patients with low back pain: reliability and validity of the Patient Generated Index.

OBJECTIVE To evaluate the reliability and validity of the improved version of the Patient Generated Index (PGI) in patients with low back pain. METHODS The PGI was administered to 90 patients attending care in 1 of 6 institutions in Norway and evaluated for reliability and validity. The questionnaire was given out to 61 patients for re-test purposes. RESULTS The PGI was completed correctly by 80 (88.9%) patients and, of the 61 patients responding to the re-test, 50 (82.0%) completed both surveys correctly. PGI scores were approximately normally distributed, with a median of 40 (range 80), where 100 is the best possible quality of life. There were no floor or ceiling effects. The 5 most frequently listed areas affecting quality of life were pain, sleep, stiffness, socializing and housework. The test-retest intraclass correlation coefficient was 0.73. The smallest detectable changes for individual and group purposes were 32.8 and 4.6, respectively. The correlations between PGI scores and other instrument scores followed a priori hypotheses of low to moderate correlations. DISCUSSION The PGI has evidence for reliability and validity in Norwegian patients with low back pain at the group level and may be considered for application in intervention studies when a comprehensive evaluation of quality of life is important. However, the smallest detectable change, of approximately 30 points, may be considered too large for individual purposes in clinical applications.

Development of the rehabilitation patient experiences questionnaire: data quality, reliability and validity in patients with rheumatic diseases.

OBJECTIVE To develop the Rehabilitation Patient Experiences Questionnaire for patients undergoing rehabilitation for rheumatological disorders. METHODS Development of the instrument was based on literature review and adaptation of the Patient Experiences Questionnaire. The instrument was piloted and then administered in a multicentre cohort study of 12 rehabilitation units. RESULTS The survey included 435 patients, of which 412 (94.7%) responded to the Rehabilitation Patient Experiences Questionnaire. Following principal component analysis, the initial 27 items were reduced to 18 items and 4 scales: rehabilitation care and organization, information and communication, availability of staff, and social environment. Item--total correlations ranged from 0.77 to 0.87. Cronbachs alpha exceeded the criterion of 0.7, and was 0.87, 0.86, 0.78, and 0.77 for the 4 scales, respectively. Construct validity was supported by correlations between the 4 scales and responses to individual questions, which were largely in the direction as hypothesized. Overall, patients reported good experiences. There were statistical differences across the rehabilitation settings in staff availability (p = 0.001) and social environment (p = 0.002), but no difference in care and organization and information/communication (p > 0.05). CONCLUSION The 18-item Rehabilitation Patient Experiences Questionnaire is a promising outcome measure of experiences related to rehabilitation in patients with rheumatic diseases across different clinical settings. :

Illness perceptions in patients receiving rheumatology rehabilitation: association with health and outcomes at 12 months

BackgroundIllness perceptions have been found to change over time and following health care. Hence, addressing illness perceptions alongside existing health care interventions may be important for the sustainment of health gains following rehabilitation. The aim of this study was to measure the illness perceptions of patients receiving inpatient rheumatology rehabilitation and assess the association with aspects of health and outcomes at baseline, discharge and 12 months.MethodsPatients with a rehabilitation stay of one week or more at three institutions in Norway in 2009 were invited to participate in the study. At baseline, discharge and 12 months, patients completed The Rheumatic Disease Illness Perception Questionnaire (RD-IPQ) which includes aspects of illness perceptions important to patients with rheumatic diseases. Stepwise regression analysis was used to assess associations between RD-IPQ scores and different aspects of health at baseline and follow-up after controlling for other aspects of health and sociodemographic variables.ResultsFor the 134 patients included in the study, baseline RD-IPQ scores had a mean of 58.2 (SD 14.9) on a 0–100 scale, where 100 is the worst possible. Scores showed improvement after the rehabilitation stay which were maintained at 12 months. RD-IPQ scores were positively associated with health and outcomes. At baseline RD-IPQ scores were statistically significant in explaining variation in pain, physical function and SF-36 mental health scores. Baseline RD-IPQ scores were significant in explaining fatigue, pain, SF-36 role limitations and social function scores following rehabilitation and at 12 months.ConclusionIllness perceptions as measured by the RD-IPQ were associated with health and outcomes as measured by rheumatology-specific and generic instruments. The consideration of illness perceptions as a component of rehabilitation may be important in achieving desired outcomes.