Clinimetrics Corner: The Minimal Clinically Important Change Score (MCID): A Necessary Pretense

How Should We Define Clinically Significant Improvement on Patient-Reported Outcomes Measurement Information System Test for Patients Undergoing Knee Meniscal Surgery?

PURPOSE

The purpose of the study was to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds for the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) computerized adaptive test (CAT) instrument in patients undergoing arthroscopic meniscal surgery.

METHODS

The PROMIS PF CAT was administered preoperatively and postoperatively to patients undergoing arthroscopic meniscal surgery. At 6 months postoperatively, patients graded their knee function based on a domain-specific anchor question. A satisfaction anchor question was used to indicate achievement of the PASS. Receiver operating characteristic analysis determined the relevant psychometric values. Cutoff analysis was performed to find preoperative patient-reported outcome scores predicting achievement of clinically significant outcomes (CSOs).

RESULTS

A total of 73 patients (41.1% female patients) were included, with a mean age of 44.9 ± 12.8.0 years and average follow-up period of 24.0 ± 1.2 weeks. The MCID on the PROMIS PF CAT was calculated to be 2.09 (area under the curve [AUC], 0.75; 95% CI, 0.57-0.94). Net score improvement equivalent to achievement of SCB was found to be 6.50 (AUC, 0.77; 95% CI, 0.55-0.99). The PASS was found to be 46.1 (AUC, 0.86; 95% CI, 0.76-0.96). A preoperative score below 37.6 on the PROMIS PF CAT predicted achievement of the MCID (AUC, 0.76; 95% CI, 0.62-0.87), whereas scores above 41.9 predicted achievement of the PASS (AUC, 0.77; 95% CI, 0.65-0.90). Higher baseline functional status and the absence of pre-existing arthritis were also found to be statistically significant predictors of achieving CSOs.

CONCLUSIONS

Our study defined the MCID, SCB, and PASS for the PROMIS PF CAT. We found that a preoperative score below 37.6 was predictive of achieving a meaningful clinical change with surgery whereas a preoperative score above 41.9 was predictive of patients who would attain an acceptable postoperative health state. In addition, exercising more days per week and the absence of arthritis increased the likelihood of achieving postoperative CSOs.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Convergent Validity and Minimal Clinically Important Difference of the Maugeri Foundation Respiratory Failure Questionnaire (MRF-28) and the Chronic Obstructive Pulmonary Disease-Specific Health-Related Quality of Life questionnaire (VQ11)

Purpose

Short and easy questionnaires have been developed to assess the health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD), such as the Maugeri Foundation Respiratory Failure Questionnaire (MRF-28) and the COPD-specific HRQoL Questionnaire (VQ11). Both are valid, reliable, and sensitive, but their minimal clinically important differences (MCID) are unknown. Consequently, this study aimed to confirm the convergent validities of the MRF-28 and VQ11 and establish their MCID. A retrospective design was used to evaluate the effect of individual home-based pulmonary rehabilitation (PR) in 400 COPD patients.

Patients and methods

Exercise tolerance, anxiety and depression based on the Hospital Anxiety and Depression Scale (HADS), and HRQoL using three questionnaires (MRF-28, VQ11, and the Visual Simplified Respiratory Questionnaire: VSRQ) were assessed before and after an individualized home-based PR program (5 sessions of 30-45 mins/week for 8 weeks, including a weekly session supervised by a team member).

Results

PR improved all measured variables (p < 0.0001). The correlations were significant (p < 0.0001) between VSRQ and MRF-28 (r = -0.685 at baseline and r = -0.686 after the PR program), and between VSRQ and VQ11 (r = -0.691 at baseline and r = -0.753 after the PR program). Moreover, changes in score (delta between after and before PR program) of VSRQ were also significantly correlated (p < 0.0001) to changes in score of MRF-28 (r = -0.372) and VQ11 (r = -0.423). Last, we calculated MCID of -5.2 and -2.0 units for MRF-28 and VQ11, respectively.

Conclusion

The MRF-28 and VQ11 can be used in routine practice to evaluate the effects of PR on the HRQoL of COPD patients, with MCID of -5.2 and -2.0, respectively.

The 22-Item Sinonasal Outcome Test as a Tool for the Assessment of Quality of Life and Symptom Control in Allergic Rhinitis

Background

The 22-item Sinonasal Outcome Test (SNOT-22) is a validated patient-reported outcome measure for chronic rhinosinusitis and in many circumstances is used in rhinology/otolaryngology clinics to assess sinonasal symptoms in general when a formal diagnosis is not established, although with little support for such usage.

Objective

To assess the utility of the SNOT-22 as a reflection of quality of life (QOL) and symptom control for patients with allergic rhinitis (AR).

Methods

Retrospective review of 353 patients with persistent AR. Each patient completed a SNOT-22, 5-item EuroQol general health-related QOL (EQ-5D) questionnaire (from which the visual analog scale [VAS] was used), and Rhinitis Control Assessment Test (RCAT). In addition, 95 patients also completed these questionnaires 1 to 12 months later.

Results

The SNOT-22 was negatively correlated with the EuroQol 5-dimensional visual analog scale (EQ-5D VAS; r = −.45, 95% confidence interval [CI]: −0.53 to −0.36, P < .001) and RCAT ( r = −.62, 95% CI: −0.68 to −0.55, P < .001), with excellent internal consistency. The SNOT-22 demonstrated responsiveness, with mean change of −5.8 (95% CI: −8.9 to −2.6, P < .001) from pre- to posttreatment. The change in SNOT-22 over the treatment period was correlated with change in EQ-5D VAS ( r = −.28, 95% CI: −0.46 to −0.07, P = .008) and RCAT ( r = −.56, 95% CI: −0.69 to −0.41, P < .001). The minimal clinically important difference was calculated to be between 6 and 11.

Conclusion

The SNOT-22 has utility to assess QOL and symptom control in AR, and it is both reliable and responsive in its application to patients with AR. The SNOT-22 may therefore be a convenient and versatile tool in the clinical assessment of patients with AR.

Minimal Clinically Important Difference After Carpal Tunnel Release Using the PROMIS Platform

PURPOSE

In light of recently-proposed quality measures for carpal tunnel release (CTR), elucidating the minimal clinically important difference (MCID) for selected outcome measures will be important when interpreting treatment responses. Our purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the short Disabilities of the Arm, Shoulder, and Hand (QuickDASH) following CTR.

METHODS

Adult patients undergoing isolated unilateral CTR between July 2014 and October 2016 were identified. Outcomes included the PROMIS Upper Extremity (UE) Computer Adaptive Test (CAT), Physical Function (PF) CAT, QuickDASH, and Pain Interference (PI) CAT. For inclusion, pretreatment baseline (within 60 days of surgery) and postoperative (6-90 days) UE or PF CAT scores were required, as well as a response on a 5-point Likert scale to the question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" The MCID was calculated using SD and minimum detectable change (MDC) distribution methods.

RESULTS

In response to the Likert scale question, 88.6% of patients reported improvement at a mean of 14.8 days after surgery. The infrequency of patients reporting no change (5 of 44; 11.4%) precluded calculation of a statistically sound anchor-based MCID value. The MCID values, as calculated using the one-half SD method, were 3.6, 4.6, 10.4, and 3.4 for the UE CAT, PF CAT, QuickDASH, and PI CAT, respectively.

CONCLUSIONS

We have calculated MCID values for the UE CAT, PF CAT, QuickDASH, and PI CAT for patients undergoing CTR. Although the small number of patients reporting no change and minimal change after surgery precluded an anchor-based MCID calculation, we report estimates using the one-half SD method for the MCID following CTR.

CLINICAL RELEVANCE

These MCID estimates will be helpful when interpreting CTR clinical outcomes and for powering prospective trials.

Impact of transsphenoidal surgery for pituitary adenomas on overall health-related quality of life: a longitudinal cohort study

Background: Previous studies show a moderate improvement in health-related quality of life (HRQoL) following transsphenoidal surgery for pituitary adenomas, but no consistent predictors of HRQoL outcome have been identified. We aimed to evaluate overall HRQoL changes following such surgery, and assess potential patient or tumour characteristics that predict HRQoL outcome.Materials and methods: Sixty adult patients undergoing transsphenoidal resection of pituitary adenomas were prospectively enrolled. They completed the EQ-5D 3L, a generic HRQoL questionnaire, preoperatively, and at one (n = 57) and six months (n = 56) postoperatively. HRQoL was assessed as both postoperative change in median EQ-5D 3L score, and as change greater than the minimal clinically important difference (MCID) in EQ-5D 3L score. A multivariable logistic regression analysis was performed to assess potential predictors of clinically significant HRQoL changes (>MCID) at six months postoperatively.Results: There was a slight, but statistically significant, improvement in median EQ-5D 3L scores at six months postoperatively compared to preoperatively. Sixteen patients (29%) reported a clinically significant improvement in HRQoL at six months postoperatively, and larger preoperative tumour volume was a statistically significant predictor of such improvement. Eight patients (14%) reported a clinically significant deterioration in HRQoL at six months, but none of the assessed variables predicted such deterioration.Conclusions: Patient-reported overall HRQoL improved slightly after transsphenoidal surgery for pituitary adenomas at group level. Patients with larger tumours might have more HRQoL benefits from surgery, but the mechanisms behind the predictive nature of tumour volume remain unknown.

Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Thoracic paravertebral block is the preferred regional anesthetic technique for breast cancer surgery, but concerns over its invasiveness and risks have prompted search for alternatives. Pectoralis-II block is a promising analgesic technique and potential alternative to paravertebral block, but evidence of its absolute and relative effectiveness versus systemic analgesia (Control) and paravertebral block, respectively, is conflicting. This meta-analysis evaluates the analgesic effectiveness of Pectoralis-II versus Control and paravertebral block for breast cancer surgery.

Methods

Databases were searched for breast cancer surgery trials comparing Pectoralis-II with Control or paravertebral block. Postoperative oral morphine consumption and difference in area under curve for pooled rest pain scores more than 24 h were designated as coprimary outcomes. Opioid-related side effects, effects on long-term outcomes, such as chronic pain and opioid dependence, were also examined. Results were pooled using random-effects modeling.

Results

Fourteen randomized trials (887 patients) were analyzed. Compared with Control, Pectoralis-II provided clinically important reductions in 24-h morphine consumption (at least 30.0 mg), by a weighted mean difference [95% CI] of −30.5 mg [−42.2, −18.8] (P &lt; 0.00001), and in rest pain area under the curve more than 24 h, by −4.7cm · h [−5.1, −4.2] or −1.2cm [−1.3, −1.1] per measurement. Compared with paravertebral block, Pectoralis-II was not statistically worse (not different) for 24-h morphine consumption, and not clinically worse for rest pain area under curve more than 24 h. No differences were observed in opioid-related side effects or any other outcomes.

Conclusions

We found that Pectoralis-II reduces pain intensity and morphine consumption during the first 24 h postoperatively when compared with systemic analgesia alone; and it also offers analgesic benefits noninferior to those of paravertebral block after breast cancer surgery. Evidence supports incorporating Pectoralis-II into multimodal analgesia and also using it as a paravertebral block alternative in this population.

Maintenance of quality of life improvement for patients with chronic pain and obesity after interdisciplinary multimodal pain rehabilitation - A study using the Swedish Quality Registry for Pain Rehabilitation

BACKGROUND

Throughout the world many people have both obesity and chronic pain, comorbidities that decrease Health-Related Quality of Life (HRQoL). It is uncertain whether patients with comorbid obesity can maintain improved HRQoL after Interdisciplinary Multimodal Pain Rehabilitation (IMMPR).

METHODS

Data from 2016, 2017, and 2018 were obtained from a national pain database for Swedish specialized pain clinics and collected at three time points: Pre-IMMPR; Post- IMMPR; and 12-month follow-up (FU-IMMPR). Participants (N = 872) reported body weight, height, pain aspects, and HRQoL (RAND 36-Item Health Survey). Severe obesity (Body Mass Index, BMI ≥35 kg/m² ) was defined according to WHO classifications. We used linear mixed regression models to examine BMI group differences in HRQoL over time.

RESULTS

More than 25% of patients (224/872) were obese and nearly 30% (63/224) of these were severely obese. All BMI groups improved significantly in both physical and mental composites of HRQoL after IMMPR (Pre- vs. Post-IMMPR, p < .001). The improvements were maintained at a 12-month follow-up (Post- vs. FU-IMMPR, p > .05). The severe obesity group had the lowest physical health score and least improvement (pre- vs. FU-IMMPR, Cohen's d = o.422, small effect size). Severe obesity had negative impact on physical health (β = -4.39, p < .05) after controlling for sociodemographic factors and pain aspects.

CONCLUSION

Improvements in HRQoL after IMMPR were achieved and maintained across all weights, including patients with comorbid obesity. Only severe obesity was negatively associated with physical health aspects of HRQoL.

SIGNIFICANCE

Patients with chronic pain and comorbid obesity achieve sustained Health-Related Quality of Life (HRQoL) improvements from Interdisciplinary Multimodal Pain Rehabilitation (IMMPR). This finding suggests that rehabilitation professionals should consider using IMMPR for patients with comorbid obesity even though their improvement may not reach the same level as for non-obese patients.

Perioperative duloxetine for acute postoperative analgesia: a meta-analysis of randomized trials

BACKGROUND

Multimodal analgesia is a fundamental part of modern surgery and enhanced recovery pathways. Duloxetine, a serotonin and norepinephrine reuptake inhibitor, has been validated for the treatment of chronic neuropathic pain. The evidence for duloxetine as an adjunct for the treatment of acute postoperative pain remains controversial. We conducted a meta-analysis to determine the efficacy of duloxetine in the acute perioperative setting.

METHODS

A literature search was conducted in the major databases (PubMed, EMBASE and Google Scholar) for randomized controlled trials (RCTs) evaluating duloxetine compared with placebo control for acute postoperative pain. The primary outcome was postoperative pain assessed at 2, 4, 6, 24 and 48 hours time frames. Secondary outcomes included postoperative opioid administration, as well as side effects, such as postoperative nausea/vomiting (PONV), pruritus, dizziness and headache.

RESULTS

574 patients (n=9 RCTs) were included in the analysis, divided between duloxetine (n=285 patients) and placebo (n=289 patients). Duloxetine use was associated with a significant reduction in pain scores as early as 4 (mean difference (MD) -0.9, 95% CI -1.33 to -0.47) and as late as 48 (MD -0.94, 95% CI -1.56 to -0.33) hours postoperatively compared with placebo. In addition, duloxetine was associated with a significant reduction in opioid administration at 24 (standardized MD (SMD) -2.24, 95% CI -4.28 to -0.19) and 48 (SMD -2.21, 95% CI -4.13 to -0.28) hours as well as a significant reduction in PONV (risk ratio 0.69, 95% CI 0.49 to 0.95, p=0.03) compared with placebo. There was no difference between groups in other side effects.

CONCLUSION

Duloxetine, a non-opioid neuromodulator, may provide efficacy for the treatment of acute perioperative pain. Additional prospective studies are required to establish optimal perioperative dosing regimens, role in the setting of a comprehensive multimodal analgesic plan and impact on chronic postsurgical pain.

PROSPERO REGISTRATION NUMBER

CRD42019121416.

Minimal clinically important change in patients with cervical dystonia: Results from the CD PROBE study

OBJECTIVE

To determine the minimal clinically important change (MCIC) on Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores using data from Cervical Dystonia Patient Registry for Observation of OnabotulinumtoxinA Efficacy (CD PROBE), which captured real-world practices and outcomes.

METHODS

Changes in the baseline TWSTRS scores (point and percentage changes) were compared to changes in the Patient and Clinician Global Impression of Change (PGIC and CGIC) ratings. Using logistic regression, the discrimination of the model was determined.

RESULTS

Among the 479 patients who completed all TWSTRS assessments, the mean TWSTRS Total score significantly decreased from baseline (39.2) to the final visit (27.1) (P < .0001). TWSTRS Total score point changes that compared with PGIC assessments "very much improved," "much improved" or better, and "minimally improved" or better were -11, -9, and -8, respectively, and were similar to previously published changes (ie, a decrease of ≥10 points). TWSTRS Total score data met indicators of good cutoffs for discrimination of the model including ≥70% percentage of outcomes correctly classified when compared with PGIC ratings. The TWSTRS Total score mapped to PGIC and CGIC ratings better than any TWSTRS subscale score.

CONCLUSIONS

The MCIC for improvement was ≥8 points based on mean TWSTRS Total scores in patients with cervical dystonia when compared against the patient-based evaluation of benefit (PGIC).

Cultural Variations in the Minimum Clinically Important Difference Thresholds for SRS-22R After Surgery for Adult Spinal Deformity

STUDY DESIGN

Longitudinal cohort.

OBJECTIVE

To calculate the minimum clinically important difference (MCID) threshold values for the Scoliosis Research Society-22R (SRS-22R) in Japanese patients with adult spinal deformity (ASD) and to compare the results with previously reported values in a North American population.

SUMMARY OF BACKGROUND DATA

The SRS-22R has been shown to be reliable, valid, and responsive to change in patients with ASD undergoing surgery. The MCID quantifies a threshold value of improvement that is clinically relevant to the patient. We hypothesize that MCID threshold values of SRS-22R differ between different cultural groups.

METHODS

We identified ASD patients who completed the SRS-22R preoperatively and the SRS-30 at minimum two years after surgery. Answers to the last seven questions of the SRS-30 were used as anchors to determine the MCID for the SRS-22R Activity, Pain, Appearance, Mental domains, and Total score using receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 122 (16 male, 106 female) patients were included in the analysis. There was a statistically significant improvement in all domain scores from preoperation to two years postoperation. There was a statistically significant difference in change in domain score among the responses to the anchors (p < .05). The ROC curve analysis yielded MCID values of 0.90 for Activity (area under the curve [AUC] = 0.766), 0.85 for Pain (AUC = 0.637), 1.05 for Appearance (AUC = 0.764), and 0.70 for Mental (AUC = 0.641) domain, 1.05 for Total score (AUC = 0.670). Except for Appearance, these MCID thresholds were higher compared with values reported in patients from North America (Activity = 0.60, Pain = 0.40, Appearance = 1.23, Total = 0.71).

CONCLUSIONS

Results of this study showed that cultural variations exist for MCID threshold values for SRS-22 Activity, Pain, Mental domains, and Total score after surgical treatment of ASD.

Functional assessment using short tests in a patient with Pompe disease receiving enzyme replacement therapy: case report

Introduction: Pompe disease is characterized by the deficiency of the acid alfa glucosidase enzyme, which leads to a glycogen accumu­lation mainly in cardiac and skeletal muscles. Its onset may be early or late; the late form is more difficult to handle given the variety of presenta­tions. Enzyme replacement therapy has shown to improve gross motor function and lung function in patients.Case description: Female patient who presented chronic quadriparesis. She was diagnosed with Pompe disease, which required enzyme replace­ment therapy that helped improve the symptoms, which was evident with the performance of rapid functional evaluation tests.Discussion: Enzyme replacement therapy in Pompe disease modifies the natural history of the disease. A brief review of the literature about the functional tests that can be used to assess a patient with this disorder is presented.Conclusion: The 10-meter walk test, one-leg stance test, cervical flexion in supine position, five times sit to stand test, and coin rotation task are useful for clinical evaluation in patients with Pompe disease receiving enzyme replacement therapy.

Effects of training with a neuro-mechano stimulator rehabilitation bicycle on functional recovery and paired-reflex depression of the soleus in individuals with incomplete paralysis: a proof-of-principle study

Aim: The present study describes the training effects of a novel motorized bicycle-like device for individuals with incomplete spinal cord injury. Methods: Participants were five individuals with motor incomplete spinal cord injury (56 ± 7 years). Four of five participants received two 30-min sessions of training: one with, and one without, mechanical stimulation on the plantar surface of the foot; soleus paired H-reflex depression was examined before and after each session. Three of five participants received 24 sessions of 30-min of training (long-training). Following the long-training, balance, walking and spasticity improvements were assessed using validated clinical outcome measures, in addition to the H-reflex assessment. Results: One cycling session with mechanical stimulation yielded 14% and 32% more reflex depression in participants with moderate spasticity (n = 2/4). The same trend was not observed in non-spastic participants (n = 2/4). All participants who participated in the long-training had spasticity and showed reduced spasticity, improved walking speed, endurance and balance. Conclusions: Overall, participants with spasticity showed increased soleus H-reflex suppression after one training session with mechanical stimulation and reduced spasticity scores after long training. We interpret this as evidence that the training influenced both presynaptic and postsynaptic inhibitory mechanisms acting on soleus motoneurons. Therefore, this training has the potential to be a non-invasive complementary therapy to reduce spasticity after incomplete spinal cord injury.

Patient-reported outcomes of adalimumab, phototherapy, and placebo in the Vascular Inflammation in Psoriasis Trial: A randomized controlled study

BACKGROUND

There are limited data about the impact of narrowband ultraviolet B phototherapy on patient-reported measures of health-related quality of life.

OBJECTIVE

To evaluate the impact of adalimumab and phototherapy on health-related quality of life.

METHODS

We examined patient-reported outcomes from a multicenter, randomized, placebo-controlled trial (ClinicalTrials.gov no. NCT01553058). The Dermatology Life Quality Index and EQ-5D-3L were evaluated every 4 weeks.

RESULTS

We enrolled 97 patients: 30.9% were female, mean age was 43.5 years (standard deviation, 14.0), and median Psoriasis Area and Severity Index score was 16.7 (interquartile range, 13.9-21.6). At week 12, patients being treated with adalimumab (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.02-8.17) and phototherapy (OR, 8.83; 95% CI, 2.47-31.57) were more likely to achieve the minimal clinically important difference in the Dermatology Life Quality Index compared with those receiving placebo. There were higher odds of achieving the minimal clinically important difference for the EQ-5D-3L Index score when comparing phototherapy versus placebo (OR, 9.78; 95% CI, 2.99-31.95) and phototherapy versus adalimumab (OR, 4.07; 95% CI, 1.42-11.70).

LIMITATIONS

Small sample size, secondary analysis, generalizability.

CONCLUSION

Phototherapy and adalimumab both improve skin-related quality of life and overall health-related quality of life compared with placebo in patients with psoriasis; however, patients treated with phototherapy achieved more improvement in overall health-related quality of life compared with patients treated with adalimumab.

Virtual Reality for Pediatric Needle Procedural Pain: Two Randomized Clinical Trials

OBJECTIVE

To assess the efficacy and safety of a virtual reality distraction for needle pain in 2 common hospital settings: the emergency department (ED) and outpatient pathology (ie, outpatient laboratory). The control was standard of care (SOC) practice.

STUDY DESIGN

In 2 clinical trials, we randomized children aged 4-11 years undergoing venous needle procedures to virtual reality or SOC at 2 tertiary Australian hospitals. In the first study, we enrolled children in the ED requiring intravenous cannulation or venipuncture. In the second, we enrolled children in outpatient pathology requiring venipuncture. In the ED, 64 children were assigned to virtual reality and 59 to SOC. In pathology, 63 children were assigned to virtual reality and 68 to SOC; 2 children withdrew assent in the SOC arm, leaving 66. The primary endpoint was change from baseline pain between virtual reality and SOC on child-rated Faces Pain Scale-Revised.

RESULTS

In the ED, there was no change in pain from baseline with SOC, whereas virtual reality produced a significant reduction in pain (between-group difference, -1.78; 95% CI, -3.24 to -0.317; P = .018). In pathology, both groups experienced an increase in pain from baseline, but this was significantly less in the virtual reality group (between-group difference, -1.39; 95% CI, -2.68 to -0.11; P = .034). Across both studies, 10 participants experienced minor adverse events, equally distributed between virtual reality/SOC; none required pharmacotherapy.

CONCLUSIONS

In children aged 4-11 years of age undergoing intravenous cannulation or venipuncture, virtual reality was efficacious in decreasing pain and was safe.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trial Registry: ACTRN12617000285358p.

A Comprehensive Review of Patient-reported Outcomes in Patients With Chronic Liver Diseases

Chronic liver disease (CLD) is a global health problem with chronic viral hepatitis, alcohol-related liver disease, and nonalcoholic fatty liver disease being important causes of mortality. Besides its clinical burden, patients with CLD also suffer from impairment of their health-related quality of life and other patient-reported outcomes (PRO). In this context, a combination of both clinical and PROs will allow assessment of the comprehensive burden of liver disease on patients. PROs cannot be observed directly and must be assessed by validated questionnaires or tools. Various tools have been developed to accurately measure PROs in patients with CLD, including generic and disease-specific questionnaires such as Short Form-36, Chronic Liver Disease Questionnaire and its subtypes. It is important to note that PRO instruments can be used to appreciate the impact of the natural history of CLD or of treatment on patients' experiences. This review summarizes PRO assessment in different types of liver disease and different tools useful to investigators and clinicians who are interested in this aspect of patients' experience.

Evaluation of Self-Help Cognitive Behavioural Therapy for Children's Dental Anxiety in General Dental Practice

Dental anxiety is very common; however, there is a lack of studies focusing on reducing children’s dental anxiety. One such initiative, the guided self-help cognitive behavioural therapy (CBT) resources ‘Your teeth, you are in control’, reduces dental anxiety in children attending paediatric dentistry clinics. This service evaluation aims to investigate whether such CBT resources reduce children’s dental anxiety when implemented in general dental practice. A convenience sample of children was given the resources by their dental practitioner. There was no control group. Children completed the Children’s Experiences of Dental Anxiety Measure (CEDAM) prior to using the resources and on completion of a course of dental treatment. Overall, 84 children were involved, with a mean age of 10.9 years; 48 were female and 59 were living in the most deprived area of England. At baseline the mean CEDAM score was 20.3, and on receiving the resource and completing treatment the mean CEDAM score was 16.4, showing a significant reduction in dental anxiety (t = 14.6, (df = 83), p < 0.001, 95% CI: 3.4–4.4). The items that improved the most were worry over having dental treatment and dental treatment being painful. The service evaluation indicates a reduction in child dental anxiety following the use of CBT resources in general practice. Further evaluation, preferably a randomised controlled trial, is needed.

Modern TKA implants are equivalent to traditional TKA implants in functional and patellofemoral joint-related outcomes

PURPOSE

To compare patient-reported outcomes measures, health-related quality of life and satisfaction rates between a new Modern TKA system (M-TKA) and an existing Traditional TKA system (T-TKA).

METHODS

Prospectively collected registry data of 65 patients who underwent T-TKA and 65 patients who underwent M-TKA at a single institution from 2014 to 2015 was reviewed. The range of motion, Knee Society Knee Score (KSKS), Function Score (KSFS), Oxford Knee Score (OKS), SF-36, satisfaction and expectation fulfilment were compared at Pre-op, 6 months and 2 years. Patellofemoral joint-related OKS subscores (3, 5, 7, 12) were also compared between the groups. Minimal clinically important difference (MCID) in OKS/SF-36 were analysed for both groups. Propensity scores generated using logistic regression were used to adjust for confounding variables, thus allowing matching of T-TKA to M-TKA in a 1:1 ratio.

RESULTS

Both groups showed a significant improvement in all measured variables at 6 month and 2 years (p < 0.001) when compared to baseline. There was no significant difference in KSKS, KSFS, OKS, SF-36 and Patellofemoral joint-related OKS subscores (3, 5, 7, 12) between the two groups (n.s.). At 2 years, there were high satisfaction rates of 89.2% and 92.2% in the T-TKA and M-TKA groups, respectively (n.s.). Similarly, both groups demonstrated high expectation fulfilment rates of 84.6% and 90.6% for the T-TKA and M-TKA groups, respectively (n.s.).

CONCLUSION

Using an extensive battery of standardized patient-reported, health-related quality of life and MCID assessments, our study demonstrated no difference in clinical outcomes between M-TKA and T-TKA that would justify the use of the newer and costlier M-TKA. Longer follow-up is necessary to evaluate the possible advantages of this new implant design.

LEVEL OF EVIDENCE

Level III, Retrospective Study.

Efficacy and safety of olopatadine-mometasone combination nasal spray for the treatment of seasonal allergic rhinitis

BACKGROUND

GSP301 nasal spray is a fixed-dose combination of olopatadine hydrochloride (antihistamine) and mometasone furoate (corticosteroid).

OBJECTIVE

To evaluate the efficacy and safety of GSP301 in patients with seasonal allergic rhinitis (SAR).

METHODS

In this double-blind study, eligible patients (≥12 years of age) with SAR were randomized 1:1:1:1 to twice-daily GSP301 (665 μg of olopatadine and 25 μg of mometasone), olopatadine (665 μg), mometasone (25 μg), or placebo for 14 days. The primary end point-mean change from baseline in average morning and evening 12-hour reflective Total Nasal Symptom Score (rTNSS)-was analyzed via a mixed-effect model repeated measures (P < .05 was considered to be statistically significant). Additional assessments included average morning and evening 12-hour instantaneous TNSS (iTNSS), ocular symptoms, individual symptoms, onset of action, quality of life, and adverse events (AEs).

RESULTS

A total of 1176 patients were randomized. GSP301 provided statistically significant and clinically meaningful rTNSS improvements vs placebo (least squares mean difference, -1.09; 95% CI, -1.49 to -0.69; P < .001) and vs olopatadine (P = .03) and mometasone (P = .02). Similar significant improvements in iTNSS were also observed with GSP301 (P < .05 for all). Furthermore, GSP301 significantly improved overall ocular symptoms, individual nasal and ocular symptoms, and quality of life vs placebo (P ≤ .001 for all). Onset of action for GSP301 was observed within 15 minutes and was maintained at all subsequent timepoints. Treatment-emergent AEs occurred in 15.6%, 12.6%, 9.6%, and 9.5% of patients in the GSP301, olopatadine, mometasone, and placebo groups, respectively.

CONCLUSION

GSP301 is efficacious and well tolerated vs placebo for treating SAR-associated nasal and ocular symptoms, with a rapid onset of action of 15 minutes in adult and adolescent patients 12 years and older.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02870205.

Interval Estimation for Minimal Clinically Important Difference and its Classification Error via a Bootstrap Scheme

With the improved knowledge on clinical relevance and more convenient access to the patient-reported outcome data, clinical researchers prefer to adopt minimal clinically important difference (MCID) rather than statistical significance as a testing standard to examine the effectiveness of certain intervention or treatment in clinical trials. A practical method to determining the MCID is based on the diagnostic measurement. By using this approach, the MCID can be formulated as the solution of a large margin classification problem. However, this method only produces the point estimation, hence lacks of ways to evaluate its performance. In this paper we introduce an m-out-of-n bootstrap approach which provides the interval estimations for MCID and its classification error, an associated accuracy measure for performance assessment. A variety of extensive simulation studies are implemented to show the advantages of our proposed method. Analysis of the chondral lesions and meniscus procedures (ChAMP) trial is our motivating example and is used to illustrate our method.

Commentary: Statistical significance and clinical significance - A call to consider patient reported outcome measures, effect size, confidence interval and minimal clinically important difference (MCID)

In healthcare research an intervention may be statistically significant based on quantitative analysis; however, simultaneously it may be relatively insignificant to the health or quality of life of patients affected by a particular condition or disease being treated by the intervention - thus may be interpreted as having low clinical significance. An understanding of statistics is fundamental for evidence informed healthcare. Patient-reported outcome measures (PROMs) direct patients to evaluate aspects of their own health, including quality of life, disability and function. Data obtained from PROMs can be used to demonstrate the impact of healthcare interventions on these elements of a person's quality of life. To interpret outcome measure data for clinical decision making, a clinician must understand the concepts of statistical significance and clinical significance. This commentary explores the concepts of patient reported outcome measures (PROMs), their statistical and clinical significance, and explores their relationship with a practical example for the clinician. Limitations of research that only reports p-values and the need to consider effect size, confidence intervals, and minimal clinically important difference are also discussed. Together, these concepts can assist the clinician to evaluate whether an intervention may be suitable for their clinical practice.

Intra-articular treatment options for knee osteoarthritis

Intra-articular drug delivery has a number of advantages over systemic administration; however, for the past 20 years, intra-articular treatment options for the management of knee osteoarthritis (OA) have been limited to analgesics, glucocorticoids, hyaluronic acid (HA) and a small number of unproven alternative therapies. Although HA and glucocorticoids can provide clinically meaningful benefits to an appreciable number of patients, emerging evidence indicates that the apparent effectiveness of these treatments is largely a result of other factors, including the placebo effect. Biologic drugs that target inflammatory processes are used to manage rheumatoid arthritis, but have not translated well into use in OA. A lack of high-level evidence and methodological limitations hinder our understanding of so-called 'stem' cell therapies and, although the off-label administration of intra-articular cell therapies (such as platelet-rich plasma and bone marrow aspirate concentrate) is common, high-quality clinical data are needed before these treatments can be recommended. A number of promising intra-articular treatments are currently in clinical development in the United States, including small-molecule and biologic therapies, devices and gene therapies. Although the prospect of new, non-surgical treatments for OA is exciting, the benefits of new treatments must be carefully weighed against their costs and potential risks.

Editorial Commentary: Outcomes After Hip Arthroscopy-Am I Better, Improved, or Who Knows?

Patient-reported outcomes are critical in the evaluation of the success of hip arthroscopy. Many different outcome scores are currently being used; however, that is a totally different subject. Most scores range from 0 to 100 or use some type of scale. The question becomes, Is a good outcome a score of 70 or 90? In many cases, it depends on the patient and his or her personal experiences. One way we gauge whether the patient is better is to use summary scores, which provide us with general goals for improvement. These include the minimal clinically important difference and substantial clinical benefit. While these are being defined, they can be used to help gauge patients' progress and provide improved treatment of patients.

Preliminary psychometric analyses and clinical performance of a caregiver self-efficacy scale for food allergy self-management

BACKGROUND

Food allergy health-related quality of life has been defined, but self-efficacy is poorly described.

OBJECTIVE

To examine the preliminary reliability, validity, and clinical performance of a novel food allergy self-efficacy index.

METHODS

An 8-item Food Allergy Self-Efficacy Questionnaire (FASEQ) was adapted for food allergy-related themes and coadministered with the Food Allergy Quality of Life Parental Burden (FAQL-PB) index to caregivers self-reporting a food allergic child (group A) and those with children followed up at a food allergy referral center clinic (group B). FASEQ split-half reliability, 2-week recall, factor analysis, and construct and discriminative validity were assessed. Multiple linear regression was used to explore predictive associations between the FAQL-PB and the FASEQ.

RESULTS

Among 2,308 caregivers, the mean FASEQ score was 2.69 (95% CI, 2.66-2.73) and was lower (better) among group A (mean FASEQ score, 2.52; 95% CI, 2.49-2.56) vs group B (mean FASEQ score, 3.75; 95% CI, 3.66-3.84; P < .001). The FASEQ Cronbach α was 0.87, and the 2-week intraclass correlation coefficient (ICC) was 0.75. Total and 6 of 8 individual FASEQ domain scores were significantly lower among caregivers with children having anaphylaxis or epinephrine use vs none and peanut or tree nut allergy vs milk or egg allergy, demonstrating good discriminative validity. Total FASEQ score was associated with FAQL-PB score (ICC, 0.13; 95% CI, 0.06-0.19; P < .001), with 6 of 8 FASEQ individual domains significantly associated (ICC range, -0.17 to 0.3; P < .01 for all). Factor analysis revealed 2 domains (medical care and social functioning) with construct validity.

CONCLUSION

We present preliminary evidence the FASEQ is a valid tool to assess caregiver food allergy self-efficacy. Self-efficacy is a distinct but related concept that captures aspects of self-management that are an important companion to health-related quality of life.

Responsiveness of the PROMIS and FAAM Instruments in Foot and Ankle Orthopedic Population

BACKGROUND:

Investigating the responsiveness of an instrument is important in order to provide meaningful interpretation of clinical outcomes. This study examined the responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), the PROMIS Pain Interference (PI), and the Foot and Ankle Ability Measure (FAAM) Sports subscale in an orthopedic sample with foot and ankle ailments.

METHODS:

Patients presenting to an orthopedic foot and ankle clinic during the years 2014-2017 responded to the PROMIS and FAAM instruments prior to their clinical appointments. The responsiveness of the PROMIS PF v1.2, PROMIS PI v1.1, and FAAM Sports were assessed using paired samples t test, effect size (ES), and standardized response mean (SRM) at 4 different follow-up points. A total of 785 patients with an average age of 52 years (SD = 17) were included.

RESULTS:

The PROMIS PF had ESs of 0.95 to 1.22 across the 4 time points (3, >3, 6, and <6 months) and SRMs of 1.04 to 1.43. The PROMIS PI had ESs of 1.04 to 1.63 and SRMs of 1.17 to 1.23. For the FAAM Sports, the ESs were 1.25 to 1.31 and SRMs were 1.07 to 1.20. The ability to detect changes via paired samples t test provided mixed results. But in general, the patients with improvement had statistically significant improved scores, and the worsening patients had statistically significant worse scores.

CONCLUSION:

The PROMIS PF, PROMIS PI, and FAAM Sports were sensitive and responsive to changes in patient-reported health.

LEVEL OF EVIDENCE:

Level II, prospective comparative study.

PROMIS and FAAM Minimal Clinically Important Differences in Foot and Ankle Orthopedics

BACKGROUND:

Establishing score points that reflect meaningful change from the patient perspective is important for interpreting patient-reported outcomes. This study estimated the minimum clinically important difference (MCID) values of 2 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the Foot and Ankle Ability Measure (FAAM) Sports subscale within a foot and ankle orthopedic population.

METHODS:

Patients seen for foot and ankle conditions at an orthopedic clinic were administered the PROMIS Physical Function (PF) v1.2, the PROMIS Pain Interference (PI) v1.1, and the FAAM Sports at baseline and all follow-up visits. MCID estimation was conducted using anchor-based and distribution-based methods.

RESULTS:

A total of 3069 patients, mean age of 51 years (range = 18-94), were included. The MCIDs for the PROMIS PF ranged from approximately 3 to 30 points (median = 11.3) depending on the methods being used. The MCIDs ranged from 3 to 25 points (median = 8.9) for the PROMIS PI, and from 9 to 77 points (median = 32.5) for the FAAM Sports.

CONCLUSIONS:

This study established a range of MCIDs in the PROMIS PF, PROMIS PI, and FAAM Sports indicating meaningful change in patient condition. MCID values were consistent across follow-up periods, but were different across methods. Values below the 25th percentile of MCIDs may be useful for low-risk clinical decisions. Midrange values (eg, near the median) should be used for high stakes decisions in clinical practice (ie, surgery referrals). The MCID values within the interquartile range should be utilized for most decision making.

LEVEL OF EVIDENCE:

Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

Measurement Properties of the Barthel Index in Geriatric Rehabilitation

OBJECTIVE

The Barthel index (BI) is a widely used observer-based instrument to measure physical function. Our objective is to assess the structural validity, reliability, and interpretability of the BI in the geriatric rehabilitation setting.

DESIGN

Two studies were performed. First, a prospective cohort study was performed in which the attending nurses completed the BI at admittance and discharge (n = 207). At discharge, patients rated their change in physical function on a 5-point Likert rating scale. To assess the internal structure of the BI, a confirmatory factor analysis was performed. Unidimensionality was defined by comparative fit index and Tucker-Lewis index of >0.95, and root mean square error of approximation of <0.06. To evaluate interpretability, floor/ceiling effects and the minimal important change (MIC) were assessed. Predictive modeling was used to calculate the MIC. The MIC was defined as going home and minimal patient-reported improvement defined as slightly or much improved physical function, which served as anchors to obtain a clinical- and patient-based MIC. A second group of 37 geriatric rehabilitation patients were repeatedly assessed by 2 attending nurses to assess reliability of the BI. The intraclass correlation coefficient, standard error of measurement, and smallest detectable change were calculated.

SETTING AND PARTICIPANTS

Patients receiving inpatient geriatric rehabilitation admitted to 11 Dutch nursing homes (n = 244).

RESULTS

Confirmatory factor analysis showed partly acceptable fit of a unidimensional model (comparative fit index 0.96, Tucker-Lewis index 0.95, and root mean square error of approximation 0.12). The clinical-based MIC was 3.1 [95% confidence interval (CI) 2.0-4.2] and the patient-based MIC was 3.6 (95% CI 2.8-4.3). The intraclass correlation coefficient was 0.96 (95% CI 0.93-0.98). The standard error of measurement and smallest detectable change were 1.1 and 3.0 points, respectively.

CONCLUSIONS/IMPLICATIONS

The structural validity, reliability, and interpretability of the BI are considered sufficient for measuring and interpreting changes in physical function of geriatric rehabilitation patients.

Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis

BACKGROUND

Mid-portion Achilles tendinopathy is prevalent within both the athletic and non-athletic populations and loading protocols for Achilles tendinopathy are effective over time, though the rate of symptom change throughout rehabilitation is unknown.

OBJECTIVE

The objective of this study was to determine the rate of change in pain and function over time in patients while completing a loading protocol for mid-portion Achilles tendinopathy.

METHODS

A systematic review and longitudinal meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases PubMed, CINAHL (Ovid) and CINAHL (EBSCO) were searched for articles published from inception until 31 July, 2017. Our search focused on clinical trials and cohort studies examining changes in pain and function when completing a loading protocol for mid-portion Achilles tendinopathy. The primary outcome measure assessing pain and function was the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire.

RESULTS

A total of 31 separate cohorts (24 studies) were eligible, with follow-up ranging from 2 weeks to 6 months. The data were pooled to create the mean (standard deviation) of change from baseline at each time point. The data demonstrated an improvement in pain and function as early as 2 weeks that appeared to peak at 12 weeks with a mean (standard deviation) of 21.11 (6.61) points of change on the VISA-A.

CONCLUSION

The improvement in pain and function during rehabilitation suggests future research should be directed toward investigating contributing mechanisms as tendon structure on imaging does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following the inception of a loading protocol. Systematic Review Registry: PROSPERO registration number: CRD42017062737 ( https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=62737 ).

What Are the MCIDs for PROMIS, NDI, and ODI Instruments Among Patients With Spinal Conditions?

BACKGROUND

As new Patient-Reported Outcomes Measurement Information System (PROMIS) instruments are incorporated into clinical practice, determining how large a change on these instruments represents a clinically relevant difference is important; the metric that describes this is the minimum clinically important difference (MCID). Prior research on MCIDs of the Neck Disability Index (NDI) and Oswestry Disability Index (ODI) has produced values ranging from 5 to 10 points, but these measures have not been presented in relation to MCID values of PROMIS instruments.

QUESTIONS/PURPOSES

To establish a comprehensive repository of MCID values calculated both with distribution-based and anchor-based methods for four outcomes instruments in spine care, we asked: (1) What are the MCIDs of the PROMIS Physical Function (PF); (2) the PROMIS Pain Interference (PI); (3) the NDI; and (4) the ODI among spine patients?

METHODS

We conducted a prospective study of previously tested diagnostic measures on 1945 consecutive patients with a reference standard applied. All patients aged 18 years and older visiting an orthopaedic spine clinic between October 2013 and January 2017 completed the PROMIS PF and PI, NDI, and ODI on tablet computers before their clinic visits. Patients were grouped by change level (self-report of meaningful change versus slight or no change) using an anchor question in comparison to baseline. Descriptive statistics, two anchor-based MCID values (mean change and receiver operating characteristic curve), and five distribution-based values (SD at 1/2 and 1/3 values and minimum detectable change [MDC] at 90%, 95%, and 99%) were analyzed four different times between 3 months and > 6 months of followup. A total of 1945 included patients with a wide range of spine conditions and varying treatments had a mean age of 58 years (SD = 15.5), were 51% (988 of 1945) male, 90% (1754 of 1945) self-identified as white, and 5% (94 of 1945) as Hispanic with 1% to 2% of patients refusing participation.

RESULTS

The PROMIS PF mean change scores in the changed group (much worse, worse, improved, or much improved) ranged between 7 and 8 points. MCID values ranged from 3 to 23 points depending on the method of calculation with a median of 8. For the PROMIS PI, mean change scores ranged from 8 to 9 points and MCID values from 1 to 24 points with a median of 8. For the NDI, mean change scores ranged from 13 to 18 points and MCID values ranged from 6 to 43 points with a median of 18. For the ODI, mean change ranged from 17 to 19 points and MCID values ranged from 7 to 51 points with a median of 24. For each instrument, distribution-based SD yielded the smallest values, followed by anchor-based methods, with MDC yielding the largest MCID values.

CONCLUSIONS

This study uses a range of methods for determining MCIDs of the PROMIS PF and PI, NDI, and ODI from anchor-based to distribution-based methods. MCIDs do not have a static value for a given outcome measure, but have a range of values and are dependent on the method calculated. The lowest MCIDs identified for the NDI and ODI are consistent with prior studies, but those at the upper range are much higher. Anchor-based methods are thought to be most relevant in the clinical setting and are more easily understood by clinicians, whereas the distribution-based MCIDs are useful in understanding population breadth. Lower MCID values may be most appropriate for screening purposes or low-risk effects, and the median or higher MCID values should be used for high-risk effects or outcomes.

LEVEL OF EVIDENCE

Level I, diagnostic study.

Sex-Based Differences of Medial Collateral Ligament and Anterior Cruciate Ligament Strains With Cadaveric Impact Simulations

Background:

Female patients sustain noncontact knee ligament injuries at a greater rate compared with their male counterparts. The cause of these differences in the injury rate and the movements that load the ligaments until failure are still under dispute in the literature.

Purpose/Hypotheses:

This study was designed to determine differences in anterior cruciate ligament (ACL) and medial collateral ligament (MCL) strains between male and female cadaveric specimens during a simulated athletic task. The primary hypothesis tested was that female limbs would demonstrate significantly greater ACL strain compared with male limbs under similar loading conditions. A secondary hypothesis was that MCL strain would not differ between sexes.

Study Design:

Controlled laboratory study.

Methods:

Motion analysis of 67 athletes performing a drop vertical jump was conducted. Kinetic data were used to categorize injury risk according to tertiles, and these values were input into a cadaveric impact simulator to assess ligamentous strain during a simulated landing task. Uniaxial and multiaxial load cells and differential variable reluctance transducer strain sensors were utilized to collect mechanical data for analysis. Conditions of external loads applied to the cadaveric limbs (knee abduction moment, anterior tibial shear, and internal tibial rotation) were varied and randomized. Data were analyzed using 1-way analysis of variance (ANOVA), 2-way repeated-measures ANOVA, and the Fisher exact test.

Results:

There were no significant differences (P = .184) in maximum ACL strain between male (13.2% ± 8.1%) and female (16.7% ± 8.3%) specimens. Two-way ANOVA demonstrated that across all controlled external load conditions, female specimens consistently attained at least 3.5% increased maximum ACL strain compared with male specimens (F_1,100 = 4.188, P = .043); however, when normalized to initial contact, no significant difference was found. There were no significant differences in MCL strain between sexes for similar parameters.

Conclusion:

When compared with baseline, female specimens exhibited greater values of ACL strain at maximum, initial contact, and after impact (33, 66, and 100 milliseconds, respectively) than male specimens during similar loading conditions, with a maximum strain difference of at least 3.5%. During these same loading conditions, there were no differences in MCL loading between sexes, and only a minimal increase of MCL loading occurred during the impact forces. Our results indicate that female patients are at an increased risk for ACL strain across all similar conditions compared with male patients.

Clinical Relevance:

These data demonstrate that female specimens, when loaded similarly to male specimens, experience additional strain on the ACL. As the mechanical environment was similar for both sexes with these simulations, the greater ACL strain of female specimens must be attributed to ligament biology, anatomic differences, or muscular stiffness.

EVALUATING THE PROGRESS OF MID-PORTION ACHILLES TENDINOPATHY DURING REHABILITATION: A REVIEW OF OUTCOME MEASURES FOR SELF- REPORTED PAIN AND FUNCTION

INTRODUCTION

Management of mid-portion Achilles tendinopathy is a challenge for both clinicians and researchers. Alteration in tendon structure, muscle performance and pain processing mechanisms have been suggested as mechanisms driving improvement in pain and function. However, few trials have used consistent outcome measures to track changes in pain and function.

OBJECTIVES

1) To identify all outcomes measures used in trials utilizing exercise-based interventions for mid-portion Achilles tendinopathy (AT) that assess self-reported pain and function and to report on the reliability and validity of the identified measures, and 2) Propose measures to optimally assess self-reported pain and function in patients with AT.

DESIGN

Literature Review.

DATA SOURCES

Three major electronic databases were searched from inception until May 2016 for studies using isometric, eccentric or isotonic loading protocols for mid-portion AT.

ELIGIBILITY CRITERIA

Randomized and non-randomized trials of isometric, eccentric or isotonic loading in people with mid-portion AT.

RESULTS

Forty-six studies were included and all outcome measures assessing self-reported pain and function were extracted. While a variety of outcome measures have been used, few have provided reliability data. There is evidence to suggest that the Victorian Institute of Sports Assessment- Achilles (VISA-A) is the only valid and reliable measure of self-reported pain and function for people with mid-portion AT. No other outcome measures have been validated in mid-portion AT.

CONCLUSION

The VISA-A remains the gold standard for assessing pain and function in mid-portion AT. However, while the validity or reliability of the Numerical Rating Scale (NRS) of pain during a functional task has not been established it may be a better measure of immediate treatment effect.

LEVEL OF EVIDENCE

5.

The Slow Down Program: A mixed methods pilot study of a mindfulness-based stress management and nutrition education program for mothers

OBJECTIVE

Stress levels have been associated with a broad range of adverse health outcomes, particularly for mothers and subsequently, their children. Mindfulness-based stress management is a tool that has effectively been utilized in several disciplines and has potential applications to eating behaviors. This paper describes the effects of an exploratory mindfulness-based stress management and nutrition education program, the Slow Down Program, on mothers' perceived stress, eating behavior, and self-efficacy.

DESIGN & SETTING

This study used a mixed methods quasi-experimental design. Nineteen mothers with young children (five or younger) participated in the study. The SDP consisted of four consecutive weekly 1.5 h sessions focused on experiential learning and facilitated discussion.

MAIN OUTCOME MEASURES

Quantitative data were collected pre- and post-intervention and included: the Perceived Stress Scale; Mindfulness Self-Efficacy Scale; and the Three-Factor Eating Questionnaire Revised-18. Qualitative data included a focus group post-intervention and an individual interview 4-6 weeks post-intervention.

RESULTS

The SDP showed significant improvements in participants' perceived stress (p = .04), uncontrolled eating (p < 0.01), cognitive restraint (p < 0.01), and mindfulness self-efficacy (p < 0.01). Qualitatively, participants also reported changes in self-efficacy and eating behaviors - specifically improvements in mindful eating, and sensory and satiety awareness.

CONCLUSIONS

The results of this pilot study demonstrate that nutrition programs incorporated with mindfulness strategies may offer positive, short-term impacts on stress reduction and eating behaviors. Additional studies are warranted across a variety of populations with more rigorous study designs to assess long-term effects.

Establishing minimum clinically important difference values for the Patient-Reported Outcomes Measurement Information System Physical Function, hip disability and osteoarthritis outcome score for joint reconstruction, and knee injury and osteoarthritis outcome score for joint reconstruction in orthopaedics

AIM

To establish minimum clinically important difference (MCID) for measurements in an orthopaedic patient population with joint disorders.

METHODS

Adult patients aged 18 years and older seeking care for joint conditions at an orthopaedic clinic took the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS^® PF) computerized adaptive test (CAT), hip disability and osteoarthritis outcome score for joint reconstruction (HOOS JR), and the knee injury and osteoarthritis outcome score for joint reconstruction (KOOS JR) from February 2014 to April 2017. MCIDs were calculated using anchor-based and distribution-based methods. Patient reports of meaningful change in function since their first clinic encounter were used as an anchor.

RESULTS

There were 2226 patients who participated with a mean age of 61.16 (SD = 12.84) years, 41.6% male, and 89.7% Caucasian. Mean change ranged from 7.29 to 8.41 for the PROMIS^® PF CAT, from 14.81 to 19.68 for the HOOS JR, and from 14.51 to 18.85 for the KOOS JR. ROC cut-offs ranged from 1.97-8.18 for the PF CAT, 6.33-43.36 for the HOOS JR, and 2.21-8.16 for the KOOS JR. Distribution-based methods estimated MCID values ranging from 2.45 to 21.55 for the PROMIS^® PF CAT; from 3.90 to 43.61 for the HOOS JR, and from 3.98 to 40.67 for the KOOS JR. The median MCID value in the range was similar to the mean change score for each measure and was 7.9 for the PF CAT, 18.0 for the HOOS JR, and 15.1 for the KOOS JR.

CONCLUSION

This is the first comprehensive study providing a wide range of MCIDs for the PROMIS^® PF, HOOS JR, and KOOS JR in orthopaedic patients with joint ailments.

Evaluation of inguinal vascular surgical scars treated with closed incisional negative pressure wound therapy using three-dimensional digital imaging-A randomized controlled trial on bilateral incisions

PURPOSE OF THE INVESTIGATION

Scar formation is an important, permanent surrogate marker for wound healing. The main aim of this randomized trial was to evaluate the effects of incisional negative pressure wound therapy (iNPWT) on scar formation in uncomplicated wound healing with 3-dimensional (3D) digital imaging.

BASIC PROCEDURES

Patients undergoing bilateral inguinal incisions after vascular surgery were randomized to receive iNPWT and standard dressing on separate sides. The incisional scars were documented at a median time of 808 days (range 394-1194) after surgery with 3D photography, which were objectively evaluated by two plastic surgeons using the Stony Brook scar evaluation scale (SBSES) and a 10-point graded numeric ranking scale (NRS10). Subjective evaluation was performed with the patient observer scar assessment scale (POSAS). Patients with surgical site infection or other wound complications were excluded to minimize bias. The p-values were calculated using McNemar's and Wilcoxon signed-rank test for paired nominal and paired continuous data, respectively.

MAIN FINDINGS

Among 33 patients, 32 patients had undergone endovascular aortic repair (EVAR) and 31 patients had transverse inguinal incisions. Objective and subjective scar evaluation showed no difference between iNPWT and standard dressing. In objective scorings, 18.8 and 21.9% received the highest possible SBSES total score in the iNPWT and standard dressing groups, while 43.8 and 37.5% received the highest possible NRS10 score, respectively. The inter-rater reliability between the two assessors for SBSES total score and NRS10 showed an intra-class correlation (ICC) of 0.78 and 0.68 for NPWT and 0.70 and 0.77 for traditional dressing, respectively.

PRINCIPAL CONCLUSION

The present randomized trial showed that iNPWT and standard dressings on closed transverse inguinal incisions after EVAR resulted in equal subtle scar formation. Objective scar evaluation with 3D images showed good inter-rater agreement.

Determination of minimally clinically important differences for JOABPEQ measure after discectomy in patients with lumbar disc herniation

BACKGROUND

It is crucial to define if changes in patient-reported outcome (PRO) measure correspond to relevant clinical improvements. Aim of this study was to determine minimally clinically important differences (MCID) of the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) in patients with lumbar disc herniation (LDH) to assess surgical success.

METHODS

A total of 127 patients with LDH consecutively referred to our clinic were enrolled into this prospective study between March 2012 and August 2015. All participants completed the JOABPEQ and the Oswestry Disability Index (ODI) score before surgery, and at 1 year after surgery. Surgical success was defined based on clinical consensus of the team and be used as anchor. The MCID value of the JOABPEQ subscales were estimated using two anchor-based methods: (I) average change procedure (responsiveness); and (II) receiver operating characteristic (ROC) curve analysis.

RESULTS

The mean age of patients was 51.2±9.4 years, and there were 68 (53.5%) male. A total of 83.5% (106 cases) showed improvement based on the clinical consensus of the spine surgeon team at last follow-up. To assess surgical success, the two MCID calculation methods generated two optimal prediction thresholds on the JOABPEQ subscales (low back pain: 19.1, 22.4; lumbar function: 21.3, 24.2; walking ability: 24.5, 27.9; social life function: 14.3, 17.1; and mental health: 12.8, 14.8) for ROC analysis and average change procedure, respectively (P<0.002 for all of subscales in two methods). For all five subscales, the sensitivity and specificity were between 61.2 and 81.1 with AUC greater than 0.70.

CONCLUSIONS

These findings support the value of the MCID to assess surgical success for the JOABPEQ subscales in patients with LDH. This estimate may be a useful tool in clinical practice.

Efficacy of proprioceptive neuromuscular facilitation compared to other stretching modalities in range of motion gain in young healthy adults: A systematic review

The objective of this study was to evaluate the efficacy of proprioceptive neuromuscular facilitation (PNF) on range of motion (ROM) gain in young healthy adults. We performed a systematic review of randomized controlled trials and quasi-randomized trials, including young healthy adults. The interventions were: PNF compared with different PNF techniques, control, other muscle stretching exercises and musculoskeletal manipulations. The outcome measures were: articular ROM and adverse effects. The final number of included studies was 46, involving 1,864 adults. There was difference on ROM comparing assisted hold-relax (HR) on diagonal plane to control, based on very low-quality evidence. There was also difference on ROM comparing assisted HR to self-HR; self-contract-relax (CR) to control; assisted CR contract to control; and assisted HR contract to control, based on low-quality evidence. Moderate-quality evidence shows that results differ between self HR and control (SMD: 0.95; 95%CI 0.03, 1.86; I²49%; P = 0.16) in terms of ROM gain. When performing the other comparisons, the results were based on low or very low-quality evidence and do not allow to state if PNF is more or less effective than other stretches for improving ROM in healthy young adults. No adverse effects were mentioned.

Age variation in the minimum clinically important difference in SRS-22r after surgical treatment for adult spinal deformity - A single institution analysis in Japan

BACKGROUND

The Scoliosis Research Society-22r (SRS-22r) has been shown to be reliable, valid and responsive to change in patients with adult spinal deformity (ASD) undergoing surgery. The minimum clinically important difference (MCID) quantifies a threshold value of improvement that is clinically relevant to the patient. Health-related quality of life scores depend on age. The purpose of this study was to assess MCID threshold values stratified by age for SRS-22r domains in patients with ASD undergoing surgical correction.

METHODS

We identified a consecutive series of 184 Japanese ASD patients who completed the SRS-22r and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) preoperatively and 1 year postoperatively. Effectiveness as measured on the JOABPEQ was used as the anchor to determine MCID for the Function, Pain, and Mental health domains using receiver-operating-characteristic (ROC) curve analysis. We performed MCID analysis stratified by age (<70 or ≥70).

RESULTS

Mean preoperative SRS-22r Function score was 2.69 improving to 3.23 at postoperatively (p < 0.001). Mean preoperative SRS-22r Pain score was 3.04 improving to 3.78 at postoperatively (p < 0.001). Mean preoperative SRS-22r Mental health score was 2.72 improving to 3.25 at postoperatively (p < 0.001). There was a statistically difference in change in domain score between "not effective" and "effective" (p < 0.001). The ROC curve analysis methods yielded MCID values of 0.58 for Function, 0.55 for Pain, and 0.70 for Mental health domains. There was difference of MCID value for Function and Mental health domain between aged <70 and ≥70; 0.78 and 0.55 for Function; 0.70 and 0.48 for Mental health.

CONCLUSION

Results of this study showed that MCID threshold values for SRS-22 Function and Mental health domains in older than 70 was lower than in younger than 70, potentially implying that older patients have lower expectation.

Suprascapular and Interscalene Nerve Block for Shoulder Surgery

Background

Interscalene block provides optimal shoulder surgery analgesia, but concerns over its associated risks have prompted the search for alternatives. Suprascapular block was recently proposed as an interscalene block alternative, but evidence of its comparative analgesic effect is conflicting. This meta-analysis compares the analgesic effect and safety of suprascapular block versus interscalene block for shoulder surgery.

Methods

Databases were searched for randomized trials comparing interscalene block with suprascapular block for shoulder surgery. Postoperative 24-h cumulative oral morphine consumption and the difference in the area under curve for pooled rest pain scores were designated as primary outcomes. Analgesic and safety outcomes, particularly block-related and respiratory complications, were evaluated as secondary outcomes. Results were pooled using random-effects modeling.

Results

Data from 16 studies (1,152 patients) were analyzed. Interscalene block and suprascapular block were not different in 24-h morphine consumption. The difference in area under the curve of pain scores for the 24-h interval favored interscalene block by 1.1 cm/h, but this difference was not clinically important. Compared with suprascapular block, interscalene block reduced postoperative pain but not opioid consumption during recovery room stay by a weighted mean difference (95% CI) of 1.5 cm (0.6 to 2.5 cm; P &lt; 0.0001). Pain scores were not different at any other time. In contrast, suprascapular block reduced the odds of block-related and respiratory complications.

Conclusions

This review suggests that there are no clinically meaningful analgesic differences between suprascapular block and interscalene block except for interscalene block providing better pain control during recovery room stay; however, suprascapular block has fewer side effects. These findings suggest that suprascapular block may be considered an effective and safe interscalene block alternative for shoulder surgery.

Responsiveness of the active wrist joint position sense test after distal radius fracture intervention

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

The active wrist joint position sense (JPS) test has been determined to be a clinically useful test for assessing wrist sensorimotor (SM) status after distal radius fracture (DRF). Its responsiveness is yet to be determined.

PURPOSE OF THE STUDY

Primary study aim was to determine the active wrist JPS test responsiveness to detect change in wrist SM status at 8 and 12 weeks after DRF treatment intervention. Secondary aims were to compare group (nonsurgical, surgical, high, and low pain) test responsiveness; compare pain-level group participants test scores; determine the relationship between test minimal clinically important difference (MCID) value and function; compare functional outcomes across assessment times; and determine the Patient Global Impression of Change Scale intrarater reliability.

METHODS

A total of 33 male and female participants were tested at baseline, 8, and 12 weeks after nonsurgical (n = 13) and surgical (n = 20) DRF treatment interventions. Distribution-based analysis encompassed both group- (ie, effect size, standardized response mean) and individual-based (ie, minimum detectable change) statistical indices. Anchor-based analysis determined the MCID value by linking test scores to the Patient Global Impression of Change Scale.

RESULTS

The active wrist JPS test is highly responsive based on effect size (8 weeks = 1.53 and 12 weeks = 2.36) and standardized response mean (8 weeks = 1.57 and 12 weeks = 2.14). Statistically significant minimum detectable change values were 4.28° and 4.94° at 8 and 12 weeks, respectively. Clinically meaningful MCID values were 5.00° and 7.09° at 8 and 12 weeks, respectively. Between treatment type and pain-level group responsiveness levels were not significantly different. High-pain participants demonstrated significantly greater JPS deficit. Test MCID values and function were significantly associated.

DISCUSSION

This is the first study to determine the active wrist JPS test responsiveness as reflected by its group- and individual-based statistical indices following DRF surgical and non-surgical interventions among low- and high-pain level participants. The statistical analysis approach, which was used to determine the aforementioned variables of the active wrist JPS test, is consistent with current research. This study's strengths included its design, methodology, and statistical approach. The study findings must be interpreted, however, within the content of several methodological limitations.

CONCLUSIONS

The active wrist JPS test was determined to be highly responsive to detect wrist SM status change at 8 and 12 weeks regardless of treatment type or pain level. Clinicians can use this test with confidence to measure clinically meaningful SM impairment after DRF treatment.

LEVEL OF EVIDENCE

2b.

Tinnitus after Simultaneous and Sequential Bilateral Cochlear Implantation

Importance

There is an ongoing global discussion on whether or not bilateral cochlear implantation should be standard care for bilateral deafness. Contrary to unilateral cochlear implantation, however, little is known about the effect of bilateral cochlear implantation on tinnitus.

Objective

To investigate tinnitus outcomes 1 year after bilateral cochlear implantation. Secondarily, to compare tinnitus outcomes between simultaneous and sequential bilateral cochlear implantation and to investigate long-term follow-up (3 years).

Study design

This study is a secondary analysis as part of a multicenter randomized controlled trial.

Methods

Thirty-eight postlingually deafened adults were included in the original trial, in which the presence of tinnitus was not an inclusion criterion. All participants received cochlear implants (CIs) because of profound hearing loss. Nineteen participants received bilateral CIs simultaneously and 19 participants received bilateral CIs sequentially with an inter-implant interval of 2 years. The prevalence and severity of tinnitus before and after simultaneous and sequential bilateral cochlear implantation were measured preoperatively and each year after implantation with the Tinnitus Handicap Inventory (THI) and Tinnitus Questionnaire (TQ).

Results

The prevalence of preoperative tinnitus was 42% (16/38). One year after bilateral implantation, there was a median difference of -8 (inter-quartile range (IQR): -28 to 4) in THI score and -9 (IQR: -17 to -9) in TQ score in the participants with preoperative tinnitus. Induction of tinnitus occurred in five participants, all in the simultaneous group, in the year after bilateral implantation. Although the preoperative and also the postoperative median THI and TQ scores were higher in the simultaneous group, the median difference scores were equal in both groups. In the simultaneous group, tinnitus scores fluctuated in the 3 years after implantation. In the sequential group, four patients had an additional benefit of the second CI: a total suppression of tinnitus compared with their unilateral situation.

Conclusion

While bilateral cochlear implantation can have a positive effect on preoperative tinnitus complaints, the induction of (temporary or permanent) tinnitus was also reported.

Clinical Trial Registration

Dutch Trial Register NTR1722.

Quality of life profile of general Vietnamese population using EQ-5D-5L

BACKGROUND

Health-related quality of life (HRQOL) is a vital benchmark to assess the effects of health interventions and policies. Measuring HRQOL of the general population is essential to establish a reference for health outcomes evaluations. However, evidence on HRQOL of general populations in low and middle income countries is very limited. This study aimed to measure HRQOL of the Vietnamese population by using the EuroQol-5 dimensions-5 levels (EQ-5D-5L) instrument and determine its associated factors.

METHODS

A cross-sectional study was performed in Hanoi with 1571 residences in Hanoi, the capital city of Vietnam. EQ-5D-5L and EQ- visual analogue scale (EQ-VAS) were used to assess HRQOL. Potential covariates included socio-demographic characteristics, having acute symptoms in the last four weeks, chronic diseases in the last three months, having multiple health issues, and health service utilisation in the last twelve months. A generalized linear model was employed to identify the association between HRQOL and covariates.

RESULTS

Overall, the mean EQ-5D utility index was 0.91 (SD = 0.15), and the mean EQ-VAS score was 87.4 (SD = 14.3). The highest proportion of respondents reporting any problems was in Usual activities (24.3%), followed by Anxiety/Depression (15.2%) and Pain/Discomfort (10.0%), while the lowest percentage was in Self-care (2.5%). Lower HRQOL composite scores were related to unemployment, lower income, higher education, living in urban areas, having chronic diseases, having multiple health issues and using health service. For any health problem self-reported by respondents, the health utility reduced by 0.02 (respiratory diseases) to 0.15 (musculoskeletal diseases).

CONCLUSIONS

Health utility of the general population and reductions for self-reported health problems in this study are useful for future population health evaluations and comparisons. It also informs the development of interventions to reduce health problems of the general population.

Quality of life profile of general Vietnamese population using EQ-5D-5L

BACKGROUND

Health-related quality of life (HRQOL) is a vital benchmark to assess the effects of health interventions and policies. Measuring HRQOL of the general population is essential to establish a reference for health outcomes evaluations. However, evidence on HRQOL of general populations in low and middle income countries is very limited. This study aimed to measure HRQOL of the Vietnamese population by using the EuroQol-5 dimensions-5 levels (EQ-5D-5L) instrument and determine its associated factors.

METHODS

A cross-sectional study was performed in Hanoi with 1571 residences in Hanoi, the capital city of Vietnam. EQ-5D-5L and EQ- visual analogue scale (EQ-VAS) were used to assess HRQOL. Potential covariates included socio-demographic characteristics, having acute symptoms in the last four weeks, chronic diseases in the last three months, having multiple health issues, and health service utilisation in the last twelve months. A generalized linear model was employed to identify the association between HRQOL and covariates.

RESULTS

Overall, the mean EQ-5D utility index was 0.91 (SD = 0.15), and the mean EQ-VAS score was 87.4 (SD = 14.3). The highest proportion of respondents reporting any problems was in Usual activities (24.3%), followed by Anxiety/Depression (15.2%) and Pain/Discomfort (10.0%), while the lowest percentage was in Self-care (2.5%). Lower HRQOL composite scores were related to unemployment, lower income, higher education, living in urban areas, having chronic diseases, having multiple health issues and using health service. For any health problem self-reported by respondents, the health utility reduced by 0.02 (respiratory diseases) to 0.15 (musculoskeletal diseases).

CONCLUSIONS

Health utility of the general population and reductions for self-reported health problems in this study are useful for future population health evaluations and comparisons. It also informs the development of interventions to reduce health problems of the general population.