Nina K. Vøllestad

The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy: A Randomized Controlled Trial

Study Design. A randomized controlled trial with stratified block design. Objectives. To evaluate a treatment program focusing on whether specific stabilizing exercises for patients with pelvic girdle pain after pregnancy reduce pain, improve functional status, and improve quality of life. Summary of Background Data. The evidence of effectiveness of treatment for pelvic girdle pain is weak. Recent research has focused on the importance of activation of muscles for motor control and stability of the lumbopelvic region. To the authors’ knowledge, the efficacy of applying these principles for pelvic girdle pain has not previously been evaluated in a randomized controlled trial. Methods. Eighty-one women with pelvic girdle pain were assigned randomly to two treatment groups for 20 weeks. One group received physical therapy with a focus on specific stabilizing exercises. The other group received individualized physical therapy without specific stabilizing exercises. Assessments were administered by a blinded assessor, at baseline, after intervention and 1 year post partum. Main outcome measures were pain, functional status and quality of life. Results. There were no dropouts. After intervention and at 1 year post partum, the specific stabilizing exercise group showed statistically and clinically significant lower pain intensity, lower disability, and higher quality of life compared with the control group. Group difference in median values for evening pain after treatment was 30 mm on the Visual Analog Scale. Disability was reduced by more than 50% for the exercise group; changes were negligible in the control group. Significant differences were also observed for physical tests, in favor of the specific exercise group. Conclusion. An individualized treatment approach with specific stabilizing exercises appears to be more effective than physical therapy without specific stabilizing exercises for women with pelvic girdle pain after pregnancy.

Motor impairments in young children with cerebral palsy: relationship to gross motor function and everyday activities

In this study we assessed the distribution of spasticity, range of motion (ROM) deficits, and selective motor control problems in children with cerebral palsy (CP), and examined how these impairments relate to each other and to gross motor function and everyday activities. Ninety-five children (55 males, 40 females; mean age 58 months, SD 18 months, range 25 to 87 months) were evaluated with the modified Ashworth scale (MAS), passive ROM, the Selective Motor Control scale (SMC), the Gross Motor Function Measure (GMFM), and the Pediatric Evaluation of Disability Inventory (PEDI). Types of CP were hemiplegia (n=19), spastic diplegia (n=40), ataxic diplegia (n=4), spastic quadriplegia (n=16), dyskinetic (n=9), and mixed type (n=7). Severity spanned all five levels of the Gross Motor Function Classification System (GMFCS). The findings highlight the importance of measuring spasticity and ROM in several muscles and across joints. Wide variability of correlations of MAS, ROM, and SMC indicates a complex relationship between spasticity, ROM, and selective motor control. Loss of selective control seemed to interfere with gross motor function more than the other impairments. Further analyses showed that motor impairments were only one component among many factors that could predict gross motor function and everyday activities. Accomplishment of these activities was best predicted by the childs ability to perform gross motor tasks.

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.

Everyday functioning in young children with cerebral palsy: functional skills, caregiver assistance, and modifications of the environment.

Everyday functioning is described in 95 children with cerebral palsy (CP; 55 males and 40 females; mean age 58 months, SD 18 months, range 25 to 87 months) using the three scales of the Pediatric Evaluation of Disability Inventory (PEDI): Functional Skills, Caregiver Assistance, and Modifications of the Environment. Types of CP in the children were hemiplegia, (n=19), spastic/ataxic diplegia, (n=44), spastic quadriplegia, (n=16), dyskinetic, (n=9), and mixed (n=7). Symptoms were grouped by severity according to the Gross Motor Function Classification System (GMFCS): 23% were classified at level I, 21% at level II, 10% at level III, 23% at level IV, and 23% level V. A large variability in functioning in mobility, self-care, and social function was seen because of the heterogeneity of children with CP. Limitations in achievement of activities, need for assistance, and use of assistive devices increased progressively with GMFCS level. Furthermore, these children differed to a great extent from the normative sample of the PEDI. Stepwise regression analysis showed that the GMFCS was a good predictor of everyday functioning with age and learning problems as significantly contributing factors, particularly in self-care and social function. In conclusion, the three scales of the PEDI represent different but strongly related aspects of everyday functioning in young children with CP.

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.

The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy: A Two-year Follow-up of a Randomized Clinical Trial

Study Design. A randomized clinical trial. Objectives. To examine the effects of a treatment program focusing on specific stabilizing exercises after a 2-year follow-up period. Summary of Background Data. An individualized treatment approach with specific stabilizing exercises is shown to be effective for women with pelvic girdle pain 1 year after delivery. No previous study has examined the long-term effects of treatment for women with postpartum pelvic girdle pain. Methods. Eighty-one women with pelvic girdle pain postpartum were assigned randomly to 2 treatment groups for 20 weeks. Patient self-reported questionnaires measuring pain, disability, and health-related quality of life were collected after 20 weeks of treatment and 1 and 2 years postpartum. Results. All 81 women returned the questionnaires for the 2-year follow-up. Sixteen were excluded from the analysis, mainly due to new pregnancies. The significant differences between the groups in functional status, pain, and physical health (SF-36) were maintained 2 years after delivery. Minimal disability was found in 85% of the specific stabilizing exercise group as compared to 47% in the control group. The control group showed significant improvement in functional status with median change score of 6.0 (Q1–Q3 of −12–0). Minimal evening pain was reported by 68% in the specific stabilizing exercise group versus 23% in the control group. However, the group differences disappeared for all measures when controlling for score level 1 year after delivery by regression analysis. Conclusion. The significant differences between the groups persisted with continued low levels of pain and disability in the specific stabilizing exercise group 2 years after delivery. Significant reduction in disability was found within the control group. Those with the highest level of disability and greatest potential for improvements recovered most, regardless of intervention group.

Functional Status and Disability Questionnaires : What Do They Assess? : A Systematic Review of Back-Specific Outcome Questionnaires

Study Design. A systematic literature review of outcome questionnaires designed for assessing functional status or disability in patients with low back pain. Objectives. To provide a comprehensive overview of all functioning/disability questionnaires used in recent years and to explore how the main concept(s) was described or defined in the original paper, the content or the domains of disability, and the measurement properties of the questionnaires. Summary of Background Data. A number of clinical tools designed for evaluating the functional status of patients with low back pain have been developed. Only a few have been reviewed earlier, and there has been little focus on the content reflected in the questionnaires. Methods. Papers including questionnaires for assessing disability, function, activity limitations, or participation restrictions in adult patients with low back pain were searched in the MEDLINE and CINAHL databases for the period from January 1996 to January 2002. Two independent and blinded researchers read and selected abstracts and questionnaires. The content of the included questionnaires was classified according to World Health Organization’s International Classification of Functioning, Disability and Health. The measurement properties were analyzed according to recommended guidelines. Results. A total of 36 back-specific questionnaires were identified. When distinguishing among a bodily, personal, and social perspective of functioning, 4 main types of content were identified. Most of the outcome questionnaires had a mixed content reflecting various constructs such as pain and symptoms, sleep disturbances, psychological dysfunctions, physical impairments, and social functions. Nine questionnaires assessed solely activities of daily living. For one-third of the questionnaires, the measurement properties were reported in only the original study. Conclusions. Although most questionnaires had their main focus on activity limitations, a considerable variation with respect to the main concept and content was found. Only a few of the questionnaires can be considered acceptably validated.

The use and impact of assistive devices and other environmental modifications on everyday activities and care in young children with cerebral palsy

Purpose. The study describes use of assistive devices and other environmental modifications, and their impact on everyday activities and care in young children with cerebral palsy (CP). Method. Ninety-five children (55 boys, 40 girls; mean age 58 months, SD 18 months) and their parents were studied using a cross-sectional design. The Pediatric Evaluation of Disability Inventory (PEDI) was applied to assess daily activities using the three measurement scales: functional skills, caregiver assistance, and modifications of the environment. Use of modifications was described related to the five severity levels of the Gross Motor Function Classifications System (GMFCS). Impact was rated on the Caregiver Assistance scale of the PEDI and on a five-point Likert scale. Results. Out of the 1075 provided environmental modifications, 980 were in regular use to support mobility, self-care and social function among 84 children. The number increased with GMFCS levels; children at levels IV and V used 80% of the modifications, with large variations between the children at same level. Adaptations of housing and transportation facilitated effective use of assistive devices. Half of the parents rated the modifications to have moderate to very large effect on the childs mobility, 25% on self-care skills, and 20% on social function. Furthermore, 65% reported that the modifications lightened the caregiving for mobility, 75% for self-care and 25% for social function. Functional independence and care demands often benefited from different types of modifications. Conclusion. The variations in use and benefits of environmental modifications indicate need of comprehensive assistive technology assessments, including child factors, family factors, technology factors and service system factors.

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.