Margreth Grotle

Obesity and osteoarthritis in knee, hip and/or hand: An epidemiological study in the general population with 10 years follow-up

BackgroundObesity is one of the most important risk factors for osteoarthritis (OA) in knee(s). However, the relationship between obesity and OA in hand(s) and hip(s) remains controversial and needs further investigation. The purpose of this study was to investigate the impact of obesity on incident osteoarthritis (OA) in hip, knee, and hand in a general population followed in 10 years.MethodsA total of 1854 people aged 24–76 years in 1994 participated in a Norwegian study on musculoskeletal pain in both 1994 and 2004. Participants with OA or rheumatoid arthritis in 1994 and those above 74 years in 1994 were excluded, leaving n = 1675 for the analyses. The main outcome measure was OA diagnosis at follow-up based on self-report. Obesity was defined by a body mass index (BMI) of 30 and above.ResultsAt 10-years follow-up the incidence rates were 5.8% (CI 4.3–7.3) for hip OA, 7.3% (CI 5.7–9.0) for knee OA, and 5.6% (CI 4.2–7.1) for hand OA. When adjusting for age, gender, work status and leisure time activities, a high BMI (> 30) was significantly associated with knee OA (OR 2.81; 95%CI 1.32–5.96), and a dose-response relationship was found for this association. Obesity was also significantly associated with hand OA (OR 2.59; 1.08–6.19), but not with hip OA (OR 1.11; 0.41–2.97). There was no statistically significant interaction effect between BMI and gender, age or any of the other confounding variables.ConclusionA high BMI was significantly associated with knee OA and hand OA, but not with hip OA.

Concurrent comparison of responsiveness in pain and functional status measurements used for patients with low back pain.

Study Design. Prospective study of two samples of patients with acute and chronic low back pain, respectively. Objectives. To compare the responsiveness of four functional status questionnaires, Roland Morris Disability Questionnaire (RMDQ), Oswestry Disability Index (ODI), Disability Rating Index (DRI), and Physical Functioning scale of the SF-36 (PFSF-36), and two pain scales, a Numerical Pain Rating Scale (NRS) and Visual Analogue Scale (VAS). Summary of Background Data. Concurrent comparisons of different outcome measurements in back patients have been requested. Methods. Norwegian versions of the scales and questionnaires were completed by 54 patients with acute (<3weeks) and 50 patients with chronic low back pain (>3 months). Clinical change was estimated on a global change index. An alternative external criterion was the expected clinical course in the two cohorts. Mean changes, standardized response mean (SRM), and area under the receiver operating characteristic (ROC) curves with cutoff point for highest sensitivity and specificity were calculated. Results. At the follow-up, 63% of the acute and 41% of the chronic sample reported improvement on the global change index. Large SRMs (1.3–2.0) and areas under the ROC curves (0.84–0.93) were found for the measurements in the acute sample. In the chronic sample, the SRMs (0.4–1.1) and areas under the ROC curves (0.65–0.83) were lower, in particular for the PFSF-36 and the VAS. There was no statistically significant difference between the responsiveness in the measurements, except for higher responsiveness in the NRS compared with the VAS when using expected clinical course as the external criterion for change. Conclusion. The results suggest that all the outcome measures were appropriate for measuring changes in functional status and pain in patients with acute low back pain, whereas among chronic patients the RMDQ, ODI, DRI, and NRS were most appropriate.

Fear-avoidance beliefs and distress in relation to disability in acute and chronic low back pain

&NA; Patients with chronic low back pain (LBP) frequently demonstrate high scores for fear‐avoidance beliefs and distress. We need better knowledge about fear‐avoidance beliefs and distress in early stages of LBP. The objectives of this study were to compare the level of fear‐avoidance beliefs and distress in patients with acute LBP to patients with chronic LBP, and to assess the relationship of fear‐avoidance beliefs and distress to disability in acute and chronic LBP. Two different back pain groups including 123 patients with acute and 233 patients with chronic LBP were studied. Main outcome measures were Oswestry Disability Index and work loss. The scores for fear‐avoidance beliefs and distress in patients with acute LBP were significantly lower than among patients with chronic LBP. The results of the multivariate regression analyses, adjusting for sociodemographic, pain and clinical variables, demonstrated that whereas fear‐avoidance beliefs for physical activity and distress were significantly associated with the Oswestry Disability Index, fear‐avoidance beliefs for work and distress were significantly associated with work loss. The associations showed the same pattern in acute and chronic LBP. In addition, several of the pain and clinical variables were significantly associated with the Oswestry Disability Index and fingertip–floor distance was associated with work loss. In conclusion, fear‐avoidance beliefs and distress influence pain‐related disability both in early acute and long‐term chronic LBP. The results replicate previous reports on the association between pain experience, fear‐avoidance beliefs, distress, and disability in chronic LBP, and extend the findings to patients at an early stage of acute LBP.

CROSS-CULTURAL ADAPTATION OF THE NORWEGIAN VERSIONS OF THE ROLAND-MORRIS DISABILITY QUESTIONNAIRE AND THE OSWESTRY DISABILITY INDEX

OBJECTIVE To evaluate reliability and construct validity of the Norwegian versions of the Roland Morris Disability Questionnaire and the modified Oswestry Disability Index. DESIGN Translation of two functional status questionnaires and a cross-sectional study of measurement properties. METHODS The questionnaires were translated and back-translated following the Guillemin criteria. The Norwegian versions were tested for 55 patients with acute low back pain and 50 patients with chronic low back pain. Test-retest with a 2-day interval was performed in a subsample of 28 patients from the chronic sample. Reliability was assessed by repeatability according to Bland and Altman, intraclass coefficient and coefficient of variation. Internal consistency was assessed by Cronbachs alpha. Concurrent construct validity was assessed with correlations between the questionnaires and the SF-36, Disability Rating Index and pain intensity. RESULTS Repeatability of the Roland Morris Disability Questionnaire was 4 points, coefficient of variation 15% and intraclass correlation coefficient 0.89, and of the modified Oswestry Disability Index 11, 12% and 0.88, respectively. Internal consistency was 0.94 for both questionnaires. The questionnaires correlated highly with the physical functioning scale of SF-36, moderately with pain, and low with mental scales of the SF-36. CONCLUSION The reliability and construct validity of the Norwegian versions of the Roland Morris Disability Questionnaire and the modified Oswestry Disability Index are acceptable for assessing functional status of Norwegian-speaking patients with low back pain.

Clinical course and prognostic factors in acute low back pain : Patients consulting primary care for the first time

Study Design. Inception cohort study. Objectives. To examine the clinical course of acute low back pain and to evaluate prognostic factors for nonrecovery. Summary of Background Data. Few studies have explored clinical course and prognostic factors in patients who consult primary care for their first time because of an episode of low back pain of <3 weeks duration. Methods. A total of 123 patients with acute low back pain <3 weeks consulting primary care for the first time were included, and 120 completed 3 months follow-up. Baseline assessments included sociodemographic characteristics, back pain history and current status, psychological questionnaires and clinical examination. Main outcome measures were pain intensity, disability by Roland Morris Disability Questionnaire, and recovery of disability. Potential prognostic factors for recovery or not were analyzed by multivariate logistic regression. Results. At 4 weeks and 3 months 76% of the patients had recovered. Mean pain intensity and mean disability scores dropped 58% and 68%, respectively, of initial levels during the 3 months. The proportion with sickness absence was 8% at 4 weeks and 6% at 3 months. Several sociodemographic, clinical, and psychological factors were of prognostic value. Compared with their respective reference categories, age above 45 years (odds ratio 4.4, 95% confidence interval 1.4–14.0), smoking (3.0, 1.1–8.5), two or more neurological signs (4.6, 1.4–14.9), a score of ≥90 on the psychosocial screening (3.1, 1.0–9.4), and high levels of distress (4.1, 1.3–12.8) were the best prognostic factors of nonrecovery at 3 months. Conclusion. During a period of 3 months, 24% of the patients had not recovered. Psychological factors and neurological signs were strongly associated with nonrecovery at 3 months. In addition to the traditional examination of neurological symptoms and signs, psychological factors should be considered already at the initial visit of an episode of low back pain.

Clinical course and impact of fear-avoidance beliefs in low back pain: prospective cohort study of acute and chronic low back pain: II.

Study Design. Prospective inception cohort study. Objectives. To compare the clinical course of fear-avoidance beliefs in acute and chronic low back pain (LBP) and investigate the contribution of fear-avoidance beliefs to predict pain and disability after 1 year. Summary of Background Data. Fear-avoidance beliefs are involved in disability development. There is little knowledge on the development of fear-avoidance beliefs among different LBP subgroups. Methods. Patients with acute (n = 123) and chronic (n = 50) LBP completed a comprehensive assessment, including the Fear-Avoidance Beliefs Questionnaire (FABQ), and were followed at 3, 6, 9, and 12 months. Results. At baseline, patients with chronic LBP had significantly higher FABQ-scores for work (FABQ-Work) than patients with acute LBP (P < 0.001), and this difference remained unchanged over 1 year (P > 0.21). At baseline, there was no statistical significant difference in FABQ-scores for physical activity (FABQ-PA) between the two groups (P = 0.57). FABQ-PA scores decreased significantly over the first 4 weeks among patients with acute LBP during follow-up and remained unchanged thereafter, whereas in the chronic sample the FABQ-PA scores were unchanged throughout the first year (time effect, P < 0.001; and interaction effect, P < 0.001). In the acute sample, FABQ-Work predicted pain (P < 0.05) and disability at 12 months (P = 0.01). In the chronic sample, FABQ-PA predicted disability at 12 months (P = 0.03). The associations between the FABQ and pain/disability disappeared with distress included in the models. Conclusion. Patients with chronic LBP had more fear-avoidance beliefs for work than patients with acute LBP. There were small changes in fear-avoidance beliefs during the year of follow-up, except for a rapid decrease during the first month in the FABQ-PA in the acute sample. Fear-avoidance beliefs predicted pain and disability at 12 months after adjusting for socio-demographic and pain variables. Distress was a stronger predictor than fear-avoidance beliefs.

Are prognostic indicators for poor outcome different for acute and chronic low back pain consulters in primary care

&NA; Few studies have investigated whether prognostic indicators, which contribute to the transition from acute to chronic low back pain (LBP), are also those which contribute to continuing persistence of chronic LBP. We compared the contribution of physical, psychological and social indicators to predicting disability after one year between consulters with LBP of less than 3 months duration and more than 3 months duration. Data from two large prospective cohort studies of consecutive patients consulting with LBP in general practices were merged, providing complete data for 258 cases with acute/subacute LBP and 668 cases with chronic LBP at 12 months follow‐up. There were significant differences between the two LBP groups in baseline characteristics and clinical course of disability, assessed by Roland Morris Disability Questionnaire, during the year of follow‐up. Adjusted associations between potential prognostic indicators and disability at 12 months were carried out in the two LBP subgroups. The final multivariable regression models showed that being non‐employed, having widespread pain, a high level of Chronic Pain Grade, and catastrophising were the strongest prognostic indicators for disability at 12 months in both LBP groups. Fear of pain was significantly associated with disability in chronic LBP. Importantly, beyond baseline disability, the effect size of the other prognostic indicators for poor outcome was rather low. These findings must continue to challenge researchers to identify useful early predictors of outcome in persons with disabling back pain, as screening and targeted treatment approaches are dependent upon prognostic indicators with clinical significance.

Prognostic factors in first-time care seekers due to acute low back pain

There is limited knowledge on prognostic factors for developing chronic low back pain (LBP) at an early stage of LBP. The objectives of this study were to investigate the clinical course of pain and disability, and prognostic factors for non‐recovery after 1‐year, in patients seeking help for the first time due to acute LBP. An inception cohort study included 123 patients with acute LBP lasting less than 3 weeks and consulting primary care for the first time. Main outcome measures were pain intensity, Roland–Morris disability questionnaire (RMQ), and sickness absence. Eleven patients (9%) did not return for the 12‐month follow‐up. There were large and significant reductions in pain intensity (P<0.001) and RMQ scores (P<0.001) during follow‐up. Patients with neurological signs showed significantly less improvement in pain (P=0.001) and RMQ (P=0.004) compared with those without neurological signs. The proportions with sickness absence due to LBP at 6, 9, and 12 months were 7%, 8%, and 9%, respectively. At 12 months, 17% of patients had not fully recovered. Multivariate logistic regression analyses showed that high scores on a psychosocial screening (acute low back pain screening questionnaire) and emotional distress (Hopkins symptom check list) were significantly associated with non‐recovery at 12 months, with odds ratios of 4.4 (95% confidence interval 1.1–17.4) and 3.3 (1.1–10.2), respectively.

RELIABILITY, VALIDITY AND RESPONSIVENESS OF THE FEAR-AVOIDANCE BELIEFS QUESTIONNAIRE: METHODOLOGICAL ASPECTS OF THE NORWEGIAN VERSION

OBJECTIVE To evaluate reliability, validity and responsiveness of the Fear-Avoidance Beliefs Questionnaire (FABQ) for use in Norwegian patients with low back pain. DESIGN A prospective cohort study with 2 groups. PATIENTS The questionnaire was tested in 123 patients with acute low back pain and 50 patients with chronic low back pain. METHODS A translation and cross-cultural adaptation was performed. Test-retest reliability was assessed in 28 patients with chronic low back pain. Responsiveness was assessed in acute low back pain. RESULTS Two factors for the FABQ were confirmed; fear-avoidance beliefs about work (FABQ-Work) and physical activity (FABQ-PA), accounting for 60% and 54% of the total variance in acute and chronic low back pain, respectively. For FABQ-Work and FABQ-PA internal consistency was 0.90 and 0.79, intra-class correlation coefficients 0.82 and 0.66, minimal detectable changes 12 and 9 points, and coefficients of variation were 16% and 23%. The FABQ correlated weakly to moderately with pain, disability, distress, and clinical variables. Standardized response means were low for FABQ-Work (0.32) and moderate (0.56) for FABQ-PA. Both FABQ subscales showed initially floor and/or ceiling effects. CONCLUSION The Norwegian FABQ version had acceptable factor structure, internal consistency, test-retest reliability and construct validity. The responsiveness of the FABQ-Work was low, and for the FABQ-PA moderate, in the acute sample.

Screening for yellow flags in first-time acute low back pain: reliability and validity of a Norwegian version of the Acute Low Back Pain Screening Questionnaire.

ObjectivesThe purpose of this study was to evaluate the reliability and construct and predictive validity of the Norwegian version of the Acute Low Back Pain Screening Questionnnaire (ALBPSQ). MethodsA prospective study with a 12-month follow-up was conducted on 123 patients with acute low back pain (LBP) seeking help in primary health care for the first time and 50 patients with chronic LBP for more than 3 months. ResultsTest-retest reliability was high with intraclass correlation coefficients of 0.90, minimal detectable change of 12 points (of a total score of 210), and coefficient of variation of 4%. Internal consistency was 0.95. Principal-components analysis revealed 3 factors explaining 49% of the variance. The ALBPSQ score correlated highly (r≥0.60) with disability variables, moderately (0.30<r<0.60) with age, pain intensity, and psychologic, questionnaires, and weakly (r≤0.30) with most sociodemographic and clinical variables. The ALBPSQ were significantly lower in acute compared with chronic LBP at all follow-up visits (P<0.001). Significant associations were found between high-risk and low-risk subgroups on the ALBPSQ and pain and disability variables during follow-up. Different cut-off points on the accuracy of predicting outcomes at 6 and 12 months’ follow-up showed high specificity and low sensitivity with a best cut-off of 90 points. DiscussionThe findings of this study provide further evidence of the utility of the ALBPSQ in clinical studies and in primary care settings (general practitioners, chiropractors, and physiotherapists) to help identify patients at risk of developing chronic LBP and disability.