Martin Verra

Clinical effectiveness of an interdisciplinary pain management programme compared with standard inpatient rehabilitation in chronic pain: a naturalistic, prospective controlled cohort study.

OBJECTIVE To compare the effects of an interdisciplinary pain management programme with those of standard in-patient rehabilitation by comprehensive biopsychosocial self--assessment. METHODS In this naturalistic prospective controlled cohort study, 164 chronic pain patients who participated in the interdisciplinary pain programme and 143 who underwent standard rehabilitation were assessed using standardized instruments. Effect differences were compared bivariately and analysed by multivariate logistic regression to control for baseline differences in the outcome variables and confounders. RESULTS On entry into the clinic, the interdisciplinary pain programme patients were younger and showed significantly worse mental and psychosocial health than the standard rehabilitation patients. At discharge, the interdisciplinary pain programme patients reported greater improvement on pain (multivariate p = 0.034), social functioning (bivariate p = 0.009), and in trend in catastrophizing and ability to decrease pain. At the 6-month follow-up, the effects experienced by the standard rehabilitation group were higher on physical functioning, social functioning, anxiety, and life control (multivariate p = 0.013-0.050). CONCLUSION Intensive interdisciplinary rehabilitation with more behavioural therapies was accompanied by a greater improvement in patients who were severely affected by pain, compared with standard rehabilitation by the end of the stay, but not in the mid-term. Highly resource-consuming patients may benefit from subsequent, individually tailored outpatient care.

Differences in pain, function and coping in Multidimensional Pain Inventory subgroups of chronic back pain: a one-group pretest-posttest study

BackgroundPatients with non-specific back pain are not a homogeneous group but heterogeneous with regard to their bio-psycho-social impairments. This study examined a sample of 173 highly disabled patients with chronic back pain to find out how the three subgroups based on the Multidimensional Pain Inventory (MPI) differed in their response to an inpatient pain management program.MethodsSubgroup classification was conducted by cluster analysis using MPI subscale scores at entry into the program. At program entry and at discharge after four weeks, participants completed the MPI, the MOS Short Form-36 (SF-36), the Hospital Anxiety and Depression Scale (HADS), and the Coping Strategies Questionnaire (CSQ). Pairwise analyses of the score changes of the mentioned outcomes of the three MPI subgroups were performed using the Mann-Whitney-U-test for significance.ResultsCluster analysis identified three MPI subgroups in this highly disabled sample: a dysfunctional, interpersonally distressed and an adaptive copers subgroup. The dysfunctional subgroup (29% of the sample) showed the highest level of depression in SF-36 mental health (33.4 ± 13.9), the interpersonally distressed subgroup (35% of the sample) a modest level of depression (46.8 ± 20.4), and the adaptive copers subgroup (32% of the sample) the lowest level of depression (57.8 ± 19.1). Significant differences in pain reduction and improvement of mental health and coping were observed across the three MPI subgroups, i.e. the effect sizes for MPI pain reduction were: 0.84 (0.44 - 1.24) for the dysfunctional subgroup, 1.22 (0.86 - 1.58) for the adaptive copers subgroup, and 0.53 (0.24 - 0.81) for the interpersonally distressed subgroup (p = 0.006 for pairwise comparison). Significant score changes between subgroups concerning activities and physical functioning could not be identified.ConclusionsMPI subgroup classification showed significant differences in score changes for pain, mental health and coping. These findings underscore the importance of assessing individual differences to understand how patients adjust to chronic back pain.

Responsiveness of the cervical Northern American Spine Society questionnaire (NASS) and the Short Form 36 (SF-36) in chronic whiplash:

Objective: To determine and compare the sensitivity to change of the condition-specific cervical Northern American Spine Society (NASS) and the generic Short Form 36 (SF-36). Design: Prospective cohort study. Subjects: One hundred and seventy five patients after whiplash injury. Interventions: Four-week inpatient interdisciplinary pain management programme. Main measures, analysis: Responsiveness of the NASS and the SF-36 was quantified by effect size and standardized response mean and compared within the same construct by the modified Jacknife test. Ability to detect improvement was compared using sensitivities determined from receiver operating characteristics curves. Results: In pain, the NASS was comparable responsive to the SF-36 at the one-month follow-up (n = 175): effect sizes: 0.62 (NASS) versus 0.61 (SF-36), P = 0.914. The NASS was less responsive than the SF-36 in function: 0.23 versus 0.63, P < 0.001 and in pain+function: 0.35 versus 0.58 (P = 0.001). These relationships remained consistent using standardized response means, at the six-month follow-up (n = 103), and in the comparison of the sensitivities. Sensitivities at one month, pain: 70% (NASS) versus 62% (SF-36), P = 0.234; function: 65% versus 80%, P = 0.002; pain+function: 68% versus 78%, P = 0.035. The six-month data were similar. Conclusions: The generic SF-36 was more responsive in function and equally responsive in pain when compared to the condition-specific NASS. The SF-36 can be recommended as a responsive instrument for measurement of pain and function in chronic whiplash syndrome.

Reliability of the Multidimensional Pain Inventory and stability of the MPI classification system in chronic back pain

BackgroundThis cross validation study examined the reliability of the Multidimensional Pain Inventory (MPI) and the stability of the Multidimensional Pain Inventory Classification System of the empirically derived subgroup classification obtained by cluster analysis in chronic musculoskeletal pain. Reliability of the German Multidimensional Pain Inventory was only examined once in the past in a small sample. Previous international studies mainly involving fibromyalgia patients showed that retest resulted in 33–38% of patients being assigned to a different Multidimensional Pain Inventory subgroup classification.MethodsParticipants were 204 persons with chronic musculoskeletal pain (82% chronic non-specific back pain). Subgroup classification was conducted by cluster analysis at 4 weeks before entry (=test) and at entry into the pain management program (=retest) using Multidimensional Pain Inventory scale scores. No therapeutic interventions in this period were conducted. Reliability was quantified by intraclass correlation coefficients (ICC) and stability by kappa coefficients (κ).ResultsReliability of the Multidimensional Pain Inventory scales was least with ICC = 0.57 for the scale life control and further ranged from ICC = 0.72 (negative mood) to 0.87 (solicitous responses) in the other scales. At retest, 82% of the patients in the Multidimensional Pain Inventory cluster interpersonally distressed (κ = 0.69), 80% of the adaptive copers (κ = 0.58), and 75% of the dysfunctional patients (κ = 0.70) did not change classification. In total, 22% of the patients changed Multidimensional Pain Inventory cluster group, mainly into the adaptive copers subgroup.ConclusionTest-retest reliability of the German Multidimensional Pain Inventory was moderate to good and comparable to other language versions. Multidimensional Pain Inventory subgroup classification is substantially stable in chronic back pain patients when compared to other diagnostic groups and other examiner-based subgroup Classification Systems. The MPI Classification System can be recommended for reliable and stable specification of subgroups in observational and interventional studies in patients with chronic musculoskeletal pain.

Effects of Inpatient Rehabilitation in Hip and Knee Osteoarthritis: A Naturalistic Prospective Cohort Study With Intraindividual Control of Effects

OBJECTIVES To quantify pain, function, and health-related quality of life in comparison with normative data, and to quantify intervention effects. DESIGN Naturalistic cohort study without a control group. Correction of the effects observed during the intervention by those observed during waiting time prior to the intervention. SETTING Inpatient rehabilitation clinic. PARTICIPANTS Patients with hip (n=88) and knee (n=164) osteoarthritis. INTERVENTION Comprehensive, multidisciplinary inpatient rehabilitation lasting 3 weeks. MAIN OUTCOME MEASURES Medical Outcomes Study 36-Item Short-Form Health Survey and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS Four or more comorbid conditions had 45.3% of the hip and 51.8% of the knee patients on entry to and discharge from the clinic. On entry, physical health and some dimensions of psychosocial health were significantly diminished compared with population norms. At discharge, hip osteoarthritis had improved by a corrected effect size of .20 to .47 in pain, .04 to .39 in function, and -.04 to .32 in psychosocial health. Knee osteoarthritis showed a corrected effect size of .43 to .62 in pain, .19 to .51 in function, and .19 to .30 in psychosocial health. All but 1 effect in WOMAC pain and WOMAC function were higher than the minimal clinically important differences. CONCLUSIONS Hip and knee osteoarthritis patients admitted to the inpatient intervention were affected by a substantial burden of disease and comorbidities. Inpatient rehabilitation resulted in small to moderate, statistically significant, and clinically important improvements in pain, function, and psychosocial health.

Exercise and other non-pharmaceutical interventions for cancer-related fatigue in patients during or after cancer treatment: a systematic review incorporating an indirect-comparisons meta-analysis

Aim To assess the relative effects of different types of exercise and other non-pharmaceutical interventions on cancer-related fatigue (CRF) in patients during and after cancer treatment. Design Systematic review and indirect-comparisons meta-analysis. Data sources Articles were searched in PubMed, Cochrane CENTRAL and published meta-analyses. Eligibility criteria for selecting studies Randomised studies published up to January 2017 evaluating different types of exercise or other non-pharmaceutical interventions to reduce CRF in any cancer type during or after treatment. Study appraisal and synthesis Risk of bias assessment with PEDro criteria and random effects Bayesian network meta-analysis. Results We included 245 studies. Comparing the treatments with usual care during cancer treatment, relaxation exercise was the highest ranked intervention with a standardisedmean difference (SMD) of −0.77 (95% Credible Interval (CrI) −1.22 to −0.31), while massage (−0.78; −1.55 to −0.01), cognitive–behavioural therapy combined with physical activity (combined CBT, −0.72; −1.34 to −0.09), combined aerobic and resistance training (−0.67; −1.01 to −0.34), resistance training (−0.53; −1.02 to −0.03), aerobic (−0.53; −0.80 to −0.26) and yoga (−0.51; −1.01 to 0.00) all had moderate-to-large SMDs. After cancer treatment, yoga showed the highest effect (−0.68; −0.93 to −0.43). Combined aerobic and resistance training (−0.50; −0.66 to −0.34), combined CBT (−0.45; −0.70 to −0.21), Tai-Chi (−0.45; −0.84 to −0.06), CBT (−0.42; −0.58 to −0.25), resistance training (−0.35; −0.62 to −0.08) and aerobic (−0.33; −0.51 to −0.16) showed all small-to-moderate SMDs. Conclusions Patients can choose among different effective types of exercise and non-pharmaceutical interventions to reduce CRF.

Using mixed methods to evaluate efficacy and user expectations of a virtual reality–based training system for upper-limb recovery in patients after stroke: a study protocol for a randomised controlled trial

BackgroundIn recent years, virtual reality has been introduced to neurorehabilitation, in particular with the intention of improving upper-limb training options and facilitating motor function recovery.Methods/DesignThe proposed study incorporates a quantitative part and a qualitative part, termed a mixed-methods approach: (1) a quantitative investigation of the efficacy of virtual reality training compared to conventional therapy in upper-limb motor function are investigated, (2a) a qualitative investigation of patients’ experiences and expectations of virtual reality training and (2b) a qualitative investigation of therapists’ experiences using the virtual reality training system in the therapy setting. At three participating clinics, 60 patients at least 6 months after stroke onset will be randomly allocated to an experimental virtual reality group (EG) or to a control group that will receive conventional physiotherapy or occupational therapy (16 sessions, 45 minutes each, over the course of 4 weeks). Using custom data gloves, patients’ finger and arm movements will be displayed in real time on a monitor, and they will move and manipulate objects in various virtual environments. A blinded assessor will test patients’ motor and cognitive performance twice before, once during, and twice after the 4-week intervention. The primary outcome measure is the Box and Block Test. Secondary outcome measures are the Chedoke-McMaster Stroke Assessments (hand, arm and shoulder pain subscales), the Chedoke-McMaster Arm and Hand Activity Inventory, the Line Bisection Test, the Stroke Impact Scale, the MiniMentalState Examination and the Extended Barthel Index. Semistructured face-to-face interviews will be conducted with patients in the EG after intervention finalization with a focus on the patients’ expectations and experiences regarding the virtual reality training. Therapists’ perspectives on virtual reality training will be reviewed in three focus groups comprising four to six occupational therapists and physiotherapists.DiscussionThe interviews will help to gain a deeper understanding of the phenomena under investigation to provide sound recommendations for the implementation of the virtual reality training system for routine use in neurorehabilitation complementing the quantitative clinical assessments.Trial registrationCliniclatrials.gov Identifier: NCT01774669 (15 January 2013)

Pain and disability following first-time lumbar fusion surgery for degenerative disorders: a systematic review protocol

BackgroundLumbar spinal fusion for degenerative disorders of the lumbar spine is frequently used, despite current research presenting inconclusive evidence. This study aims to systematically review and meta-analyse the natural course of pain and disability in patients with degenerative disorders of the lumbar spine such as spinal stenosis, spondylolisthesis, disc herniation, or discogenic low back pain to improve lumbar spinal fusion management.Methods/designAn electronic database search will be conducted up to 30 September 2015 using MEDLINE, EMBASE, CINAHL, and ZETOC database. In addition, a search for articles in press and published ahead of print, British National Bibliography for Report Literature, and OpenGrey will be conducted. Prospective cohort studies using outcome measures of pain and disability will be eligible for inclusion. Two reviewers will screen titles, abstracts, and full-text independently using predetermined inclusion and exclusion criteria. The risk of bias of included studies will be assessed with the modified version of the Quality in Prognostic Studies tool. If meta-analysis of outcome data is deemed appropriate, variance-weighted pooled means will be calculated.DiscussionThe results of this systematic review and meta-analysis may improve understanding of recovery after lumbar spinal fusion and improve lumbar spinal fusion management.Systematic review registrationPROSPERO CRD42015026922

AB1100-HPR Effect of Resistance Training in Women with Joint Hypermobility – Preliminary Results of A Randomised Controlled Trial

Background Little is known about the clinical management of persons with generalized joint hypermobility (GJH). Affected persons are often restricted in performing sports or leisure activities, as well as during work, due to pain and disability (1). Adequate muscle strength for movement control might be an important issue to overcome these restrictions. Resistance training has the possibility to improve muscle strength (2), but so far no study investigated how resistance training influences strength and muscle size in women with GJH. Objectives To evaluate the effects of a 12-week resistance training program on muscle properties of women with GJH. Methods This pragmatic randomised controlled trial included 51 hypermobile women (mean age 26.5, sd 4.5 years) with a Beighton-score of six or more (3). 27 women performed for 12 weeks a guided resistance training twice weekly and 24 women did not exercise. Before and after the 12 weeks maximum isometric strength of knee extensors and flexors was measured, which was the primary outcome. Additionally muscle cross-sectional-area (mCSA) of the thigh was measured at 33% above the knee, using peripheral quantitative computer tomography (pQCT). Data were analysed on an intention-to-treat basis. Differences between groups were tested with independent t-test at a significance level of p=0.05. Results The groups were comparable at baseline. Change of maximum strength of knee extensors in the training group was 6.3 N (sd 57.7, CI -16.5 to 29) and in the control group 8.3 N (sd 42.1, CI -9.4 to 26.1), with no significant difference between groups. Similar results were seen for knee flexors: change in training group was 8.0 N (sd 59.8, CI -15.6 to 31.7) and in control group 16.1 N (sd 42.8, CI -2.0 to 34.2). Muscle CSA of the thigh in the training group showed a significant increase (194 mm2, CI 78 to 310 mm2), compared to the control group (46 mm2, CI -25 to 118 mm2; p=0.031). Muscle mass at the thigh significantly increased 19.1 mg (sd 27.3, CI 8.3 to 29.9) in the training group, compared to the control group with 4.3 mg (sd 14.4, CI -1.8 to 10.33) mean change. Muscle density, however, showed no change in both groups. Conclusions The 12-week resistance training did not change isometric knee muscle strength, but led to a significant increase of mCSA of the thigh in women with GJH. However, this difference was only 2.4% and thus may not be clinically significant. In strength testing possibly no change was seen because the dynamic training could not be transformed to the isometric test condition and the intensity of the training might not have been high enough. The detailed analysis of the training protocols will provide further details concerning this issue. However, the small increase in muscle area may indicate that strength training is a possible option for these hypermobile women. Further analysis of the additional measurements in this trial, may give more insight into changes in pain or disability. Further research should investigate if the muscle increase could be optimized by a more intense or better supervised training. References Simmonds & Keer, Manual Therapy. 2007:298–309 Roth et al. J Am Geriatr Soc. 2001:1428–1433. Remvig et al. The Journal of Rheumatology. 2007:798–803 Acknowledgement The study was approved by the Ethics Committee of Canton Bern (222/12). Disclosure of Interest None declared

Effect of a four-week virtual reality-based training versus conventional therapy on upper limb motor function after stroke: A multicenter parallel group randomized trial

Background Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery. Objective The aim of this study was to directly compare virtual reality-based training with conventional therapy. Methods In a multi-center, parallel-group randomized controlled trial, patients at least 6 months after stroke onset were allocated either to an experimental group (virtual reality-based training) or a control group receiving conventional therapy (16x45 minutes within 4 weeks). The virtual reality-based training system replicated patients´ upper limb movements in real-time to manipulate virtual objects. Blinded assessors tested patients twice before, once during, and twice after the intervention up to 2-month follow-up for dexterity (primary outcome: Box and Block Test), bimanual upper limb function (Chedoke-McMaster Arm and Hand Activity Inventory), and subjective perceived changes (Stroke Impact Scale). Results 54 eligible patients (70 screened) participated (15 females, mean age 61.3 years, range 20–81 years, time since stroke 3.0±SD 3 years). 22 patients were allocated to the experimental group and 32 to the control group (3 drop-outs). Patients in the experimental and control group improved: Box and Block Test mean 21.5±SD 16 baseline to mean 24.1±SD 17 follow-up; Chedoke-McMaster Arm and Hand Activity Inventory mean 66.0±SD 21 baseline to mean 70.2±SD 19 follow-up. An intention-to-treat analysis found no between-group differences. Conclusions Patients in the experimental and control group showed similar effects, with most improvements occurring in the first two weeks and persisting until the end of the two-month follow-up period. The study population had moderate to severely impaired motor function at entry (Box and Block Test mean 21.5±SD 16). Patients, who were less impaired (Box and Block Test range 18 to 72) showed higher improvements in favor of the experimental group. This result could suggest that virtual reality-based training might be more applicable for such patients than for more severely impaired patients. Trial registration ClinicalTrials.gov NCT01774669.