Maureen J. Simmonds

Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain

Study Design. The psychometric properties and clinical use of a battery of physical performance measures were tested on 44 patients with low back pain and 48 healthy, pain‐free control subjects. Objectives. Reliability, validity, and clinical use of nine physical performance measures were evaluated. Summary of Background Data. Although physical performance measures have potential use in evaluation, treatment planning, and determination of treatment outcome, there is sparse systematic investigation of their reliability, validity, and clinical use. Methods. Forty‐four subjects with low back pain and 48 healthy pain‐free subjects participated. The following physical performance measures were tested: distance walked in 5 minutes; 50‐foot walk at fastest speed; 50‐foot walk at preferred speed; 5 repetitions of a sit‐to‐stand task; 10 repetitions of a repeated trunk flexion task; timed up‐and‐go task; unloaded forward reach task; loaded forward reach task; and Sorensen fatigue test. Subjects were assessed twice on 2 days. Results. All measures had excellent intertester reliability (intraclass correlation coefficient [ICC]1,1 >0.95). Test‐retest (within session) reliability was adequate for all measures (ICC1,1 >0.83) except repeated trunk flexion (ICC1,1 >0.45) in the low back pain group. Test‐retest (day‐to‐day) reliability ranged between 0.59 and 0.88 in the low back pain group and between 0.46 and 0.76 in the control group. Day‐to‐day reliability improved when the averages of two trials of repeated trunk flexion and sit‐to‐stand were used (0.76‐0.91 low back pain group and 0.62‐0.89 control group). Results of a multivariate analysis of variance showed a significant effect of group (F10,65 = 3.52, P = 0.001). Results of univariate analyses showed significant group differences on all measures except the 50‐foot walk at preferred speed and unloaded forward reach. Self‐report of disability was moderately correlated with the performance tasks (r = 0.400 to −0.603). Conclusions. The results provide support for the use of these physical performance measures as a complement to patient self‐report.

Psychosocial factors in disabling low back pain: causes or consequences?

Low back pain (LBP) is a common problem that is costly in both financial and human terms. The impact of LBP on an individual varies greatly. For some, LBP is a minor inconvenience; but for others LBP is associated with significant disability and with psychosocial dysfunction for the individual and for the family. Whether psychosocial factors are causes or consequences has been the subject of debate. This paper is a review of psychosocial factors associated with disabling LBP. It addresses the question of whether these factors are causes or consequences of the disability due to LBP. Based on this review it was concluded that there is little evidence in support of the concept of a pain-prone personality. Once LBP has occurred, the impact of the LBP on the individual and the family is influenced by the health-beliefs and coping strategies of the individual and the family. Distress appears to be secondary to physical restriction rather than pain, but the distress may aggravate the pain and thus the disability. The paper concludes with a discussion of the impact of health practitioners on pain-related disability.

Physical performance: Differences in men and women with and without low back pain

OBJECTIVEnTo determine the extent to which there may be major differences in scores on a battery of physical performance tasks among men with nonspecific, mechanical low back pain (LBP), women with LBP, healthy men, and healthy women.nnnDESIGNnCase series survey.nnnSETTINGnA referral-based orthopedic clinic.nnnPATIENTSnThirty-three men and 46 women with LBP. Control Subjects: Twenty-one men and 25 women healthy controls.nnnINTERVENTIONnCompletion of six clinician-assessed physical performance tasks and self-report inventories.nnnMAIN OUTCOME MEASUREnPerformance scores on distance walked in 5 minutes, 50-foot walk at fastest speed, repeated sit-to-stand, repeated trunk flexion, loaded forward reach, and the Sorensen fatigue tasks.nnnRESULTSnDiscriminant function analysis revealed that the four groups of subjects performed the physical tasks significantly different in two major ways: (1) healthy control subjects outperformed LBP patients, irrespective of gender, on tasks involving trunk control, coordination, and stability while withstanding heavy or quickly changing loads on the spine; (2) men outperformed women, irrespective of patient or nonpatient status, on tasks involving anthropometric features of limb length. The findings provide guidance on reasonable performance expectations for men and women patients with LBP. Future studies of treatment effectiveness also will be able to assess physical performance change in terms of the intersection between standards set by the men and women healthy control subjects and those of men and women patients. However, whether a return to nonpatient status is an appropriate treatment goal is left to future research.

Back Pain, Physical Function, and Estimates of Aerobic Capacity: What Are the Relationships Among Methods and Measures?

Cunha IT, Simmonds MJ, Protas EJ, Jones S: Back pain, physical function, and estimates of aerobic capacity: What are the relationships among methods and measures? Am J Phys Med Rehabil 2002;81:913–920. Objectives To establish the correlations of measures of self-reported disability, self-efficacy, physical performance, level of pain, and estimates of aerobic capacity (Pvo2) in subjects with low back pain. Design Fifty-one low back pain subjects, ranging in age from 26 to 65 yr, entered the study. Participants completed the Roland-Morris Disability Questionnaire and the self-efficacy questionnaire. Physical performance was evaluated by the loaded-reach test, sit/stand test, 5-min walk test, 50-foot walking test, and time to roll from right to left. Pain intensity and pain affect were measured using two visual analog scales. Pvo2 was predicted from an equation. Results The correlation coefficient among the physical performance outcomes ranged from 0.47 to 0.78. Pain measures had low correlations with measures of function but stronger correlations with other self-report measures. The disability measure correlated moderately with physical performance. Correlations between Pvo2 and all other measurements were minimal, except for the 5-min walk test. Conclusion Performance and disability were more consistent in evaluating low back pain. Pvo2 failed to correlate with most other aspects of low back pain. This study suggests that aerobic capacity might not be a primary concern for patients with low back pain.

Differences in physical performance between men and women with and without lymphoma

OBJECTIVESnTo describe and compare physical performance profiles in men and women with lymphoma with age- and gender-matched controls and to examine relationships among fatigue severity and physical performance in men and women with lymphoma.nnnDESIGNnCase-control study.nnnSETTINGnOutpatient lymphoma service in a major cancer teaching hospital.nnnPARTICIPANTSnFifty-one patients with lymphoma (26 women, 25 men), age- and gender-matched to 51 subjects without lymphoma.nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnA physical performance test battery consisting of a 50-ft (15-m) walk, a 6-minute walk, forward reach, repeated sit-to-stand, repeated reach-up, timed belt tie, sock test, and coin test. Patients also completed the Brief Fatigue Inventory (BFI).nnnRESULTSnMultivariate analysis of variance was significant for main effects of group (F(8,89)=27.12, P<.05) and gender (F(8,89)=3.09, P<.05), and there was no significant interaction. Subsequent analyses found significant differences between groups and gender in the repeated reach-up task, forward reach, 50-ft walk, and distance walked in 6 minutes. Correlations among physical performance tasks and total BFI interference scores were moderate (r range,.27-.43; P<.05) for tasks involving upper extremity, and stronger (r range,.51 to -.73; P<.05) for tasks that involved whole-body movements.nnnCONCLUSIONnThere is a leveling effect of lymphoma across gender on most tasks. The significant relations between physical performance tasks and fatigue are suggestive of the pervasive influence of fatigue on physical function.

Measures of pain and physical function in patients with low back pain

The main aim of this study was to determine whether experimentally induced pain (EXP) and simple tests of physical function can augment the assessment of patients with low back pain (LBP). A second aim was to determine the relationships between measures of pain and function in patients with low back problems attending an outpatient physical therapy clinic. Twenty-three subjects with LBP and 23 pain-free, age- and gender-matched subjects participated. The EXP threshold was measured on the arm and back using pressure and pinch dolorimeters. Clinical pain (CP) was measured with two numerical rating scales, one for pain intensity and one for pain unpleasantness. Physical function was measured using the self-report Roland and Morris Disability Questionnaire, a timed walk and a loaded reach test. Measures were obtained at entry into the study (baseline) and 2 and 6 weeks later. Comparisons of experimentally induced pain and physical function were made between groups, and over time using multivariate analyses of...

Pain and the Placebo in Physiotherapy: A benevolent lie?

Summary The aim of this paper is to discuss the mechanisms and magnitude of the placebo effect of treatment and to consider the ethical and moral implications of using placebo physiotherapy. Placebo or non-specific treatment effects were long considered to contribute a fixed fraction (one-third) to any treatment effect. Recent evidence has revealed this commonly held clinical belief to be erroneous. The placebo effect of any treatment is a highly variable and complex phenomenon that is influenced by a myriad factors. The outcome may be positive (eg analgesia) or negative (eg increased dependency on healthcare practitioners). Although the mechanisms of effect are not fully understood, evidence supports the influence of classical conditioning, anxiety reduction, and the expectations of both patients and practitioners. The relationship between patients and practitioners influences the magnitude of placebo effects as does the method of treatment presentation. A charismatic or caring practitioner can evoke analgesia with or without further treatment. And treatment presented with an air of ‘mystery‘, apparent sophistication, or positive expectation can evoke analgesia simply through the method of its presentation. Questions regarding the ethical use of treatments that are primarily placebo need to be addressed. When and under what conditions are placebo treatments acceptable in the short or long term? Is it a benevolent lie, or a regular lie, to use treatments that have only placebo effects? And, perhaps more importantly, do we know what those treatments are?

Pain and the placebo in rehabilitation using TENS and laser

The placebo effect of many health-related treatment is generally acknowledged. This paper discusses the role of the placebo in relation to pain perception and pain control. The theoretical basis of the placebo response is examined, followed by a discussion of the factors influencing the placebo response. Finally, the magnitude of the placebo response is explored specifically in relation to outcome measures and the efficacy of transcutaneous electrical nerve stimulation (TENS) and laser for pain relief.

Pain, disability, and physical therapy in older adults: issues of patients and pain, practitioners and practice

Pain in older adults is a complex multidimensional (biopsychosocial) problem that is always unpleasant and is frequently associated with physical disability, psychosocial distress, and reduced quality of life. Physical therapists knowledgeable about pain are in an excellent position to identify and manage problems related to pain and pain-related dysfunction for this older population. Unfortunately, although pain is prevalent, complex, and integral to health care, it has not been integral to health care education. Inadequate knowledge has led to inadequate assessment and management. Current evidence shows that optimum pain and disability management is predicated on a sound assessment. Optimal management of the person with pain involves education and activity guided by practitioners knowledgeable about the complexities of pain. Recommendations regarding pain and disability assessment and management by physical therapists are provided.

Does knowledge of a patient's workers' compensation status influence clinical judgments?

It is generally acknowledged that compensation payments (WCB) influence rehabilitation outcome in a negative manner. Patients receiving WCB have more treatment over a longer time period than their non compensated (NWCB) cohorts. It is not clear whether therapists (PT) perceive WCB clients as being more impaired and expect them to have a worse outcome than clients without WCB. The purpose of this study was to determine whether PTs clinical judgments are influenced by the knowledge of a patients WCB status and whether this knowledge influences their assessment findings or prognostic judgments. A convenience sample of 69 physical therapists (PTs) participated. Each PT viewed three videotaped assessments, of patients with low back pain (LBP) that differed in severity. The PT was provided with a brief history of the patient. Included in the history was a statement that the patient was (WCB group), or was not (NWCB group) in receipt of workers compensation benefits (WCB). The third group of PTs was given no information (control group) about the patient. PTs recorded physical assessment findings and made prognostic judgments about the patients. Data for the physical assessment findings and prognoses recorded by the PTs was analyzed across information groups using ANOVA. Knowledge of compensation status did not influence the PTs physical assessment findings but did influence prognostic judgments. WCB status was deemed to have a negative effect on outcome in patients with mild LBP. Additionally, NWCB status was deemed to have a positive influence on outcome in patients with severe LBP. The differences were most marked in the short term (1 month). It was concluded that PTs expectations of outcome are influenced by prior knowledge of compensation status.