Sensitivity to change of the Roland-Morris Back Pain Questionnaire: part 1

Functional Disability Due to Chronic Low Back Pain in the Geriatric Population of a Tertiary Care Hospital in North India: A Cross-Sectional Study

Background Chronic low back pain (CLBP) is one of the painful and disabling conditions affecting the young as well as the geriatric population. There is a limited body of research to find out the impact of CLBP and functional disability on geriatric adults in the Indian region. Aim This study aims to determine the prevalence of functional disability due to CLBP in the geriatric population and to investigate the correlation between functional disability due to CLBP and other sociodemographic factors. Methodology A total of 157 geriatric adults were enrolled in the study, fulfilling the inclusion and exclusion criteria. Basic sociodemographic data, along with a clinical-radiological examination, was recorded. The Numeric Pain Rating Scale (NPRS), the Roland and Morris Disability Questionnaire, and the Quebec Back Pain Disability Scale were used as study tools. Summary measures (frequency, mean, median, etc.) are calculated according to the level of measurement of variables. The point prevalence of functional disability due to CLBP in the geriatric population, along with 95% confidence intervals, has been calculated. The prevalence estimates were estimated and calculated with SD variables using a t-test, chi-square test, or Fisher's exact test under bivariate analysis. The linear/logistic regression analysis was used to control for the effects of covariates. A significance level of 5% was set for all analyses due to the exploratory nature of the study. Statistical significance was considered at p < 0.05. Results According to the Roland and Morris Disability Questionnaire, 29% (N = 46) of the study geriatric participants had a severe disability, 45% (N = 70) had a moderate disability, and 26% (N = 41) had a mild disability. According to the Quebec Back Pain Disability Scale, 34% (N = 53) had scored more than 50, and 66% (N = 104) had scored less than 50. Statistically significant correlations have been found between the level of functional disability and intensity of pain (NPRS score), gender, associated illness, current and past occupation, and clinical diagnosis of CLBP (p < 0.05). Conclusion The prevalence of functional disability due to CLBP is higher in the geriatric population. It is associated with many influencing sociodemographic factors like gender, occupation, associated musculoskeletal illness, the intensity of low back pain, and clinico-radiological diagnosis. Early identification and timely interventions to reduce functional disability due to CLBP and associated risk factors are the need of the hour. Regular back muscle exercises, ergonomic modifications, and modification of activities of daily life are recommended to prevent functional disability due to CLBP.

Improvement of muscle quality assessed using the phase angle is influenced by recovery of knee extension strength in patients with hip fractures

BACKGROUND AND AIMS

Studies reported that knee extension strength on the operated side in patients with hip fractures was not recovered to the level on the non-operated side 6 months after surgery or later. In a cross-sectional study, we revealed that a reduction in isometric knee extension muscle strength on the operated side in patients with hip fractures approximately 6 months after surgery was associated with not only a reduction in skeletal muscle mass but also a reduction in muscle quality, characterized by a reduction in the phase angle (PhA). Furthermore, the mechanisms of knee extension strength improvement can be clarified in more detail using the minimal significant change as the index of recovery. However, no longitudinal studies have examined the factors for knee extension strength improvement based on the minimal significant change in patients with hip fractures 6 months after surgery. This study aimed to longitudinally examine the factors influencing the recovery of knee extension strength based on the minimal significant change in patients with hip fractures between 2 weeks and approximately 6 months after surgery.

METHODS

In this study, the outcomes used were basic and medical information, PhA, skeletal muscle index (SMI), pain, one-leg standing time, movement control during one-leg standing, and walking speed. For PhA, SMI, pain, one-leg standing time, movement control during one-leg standing, and walking speed, the amount of change was calculated by subtracting the data at 2 weeks from the data at 6 months. Group classification was determined by dividing the patients into two groups using a previous study as a reference: recovery group if the knee extension strength value approximately 6 months after surgery minus that 2 weeks after surgery was ≥3.3 kgf and non-recovery group if the value was <3.3 kgf. Logistic regression analysis was performed to explore the association between the recovery and non-recovery groups.

RESULTS

The recovery group contained 55 patients, while the non-recovery group comprised 35 patients. The only significant factor associated with knee extension muscle strength in the recovery group was the amount of change in PhA. The odds ratio for the amount of change in PhA was 2.26. The discrimination rate of the model was 62.5%.

CONCLUSIONS

Our results suggest that recovery of knee extension strength in patients with hip fractures after surgery was mainly because of improvements in muscle quality, not improvements in muscle mass or pain.

Minimal Clinically Important Difference of Scales Reported in Stroke Trials: A Review

There is a growing awareness of the significance of using minimum clinically important differences (MCIDs) in stroke research. An MCID is the smallest change in an outcome measure that is considered clinically meaningful. This review is the first to provide a comprehensive summary of various scales and patient-reported outcome measures (PROMs) used in stroke research and their MCID values reported in the literature, including a concise overview of the concept of and methods for determining MCIDs in stroke research. Despite the controversies and limitations surrounding the estimation of MCIDs, their importance in modern clinical trials cannot be overstated. Anchor-based and distribution-based methods are recommended for estimating MCIDs, with patient self-evaluation being a crucial component in capturing the patient's perspective on their health. A combination of methods can provide a more comprehensive understanding of the clinical relevance of treatment effects, and incorporating the patient's perspective can enhance the care of stroke patients.

Item Level Psychometrics of the Dizziness Handicap Inventory in Vestibular Migraine and Meniere's Disease

OBJECTIVES

Evaluate the measurement properties of the Dizziness Handicap Inventory (DHI) using item response theory in patients diagnosed with vestibular migraine (VM) and Meniere's disease (MD).

DESIGN

One hundred twenty-five patients diagnosed with VM and 169 patients diagnosed with MD by a vestibular neurotologist according to the Bárány Society criteria in two tertiary multidisciplinary vestibular clinics and who completed the DHI at their initial visit, were included in the study. The DHI (total score and individual items) was analyzed using the Rasch Rating Scale model for patients in each subgroup, VM and MD, and as a whole group. The following categories were assessed: rating-scale structure, unidimensionality, item and person fit, item difficulty hierarchy, person-item match, and separation index, standard error of measurement, and minimal detectable change (MDC).

RESULTS

Patients were predominantly female (80% of the VM subgroup and 68% of the MD subgroup) with a mean age of 49.9 ± 16.5 years and 54.1 ± 14.2 years, respectively. The mean total DHI score for the VM group was 51.9 ± 22.3 and for the MD group was 48.5 ± 26.6 ( p > 0.05). While neither all items nor the separate constructs met all criteria for unidimensionality (i.e., items measuring a single construct), post hoc analysis showed that the all-item analysis supported a single construct. All analyses met the criterion for showing a sound rating scale and acceptable Cronbach's alpha (≥0.69). The all-item analysis showed the most precision, separating the samples into three to four significant strata. The separate-construct analyses (physical, emotional, and functional) showed the least precision, separated the samples into less than three significant strata. Regarding MDC, the MDC remained consistent across the analyses of the different samples; approximately 18 points for the full analyses and approximately 10 points for the separate construct (physical, emotional, and functional).

CONCLUSIONS

Our evaluation of the DHI using item response theory shows that the instrument is psychometrically sound and reliable. The all-item instrument fulfills criteria for essential unidimensionality but does seem to measure multiple latent constructs in patients with VM and MD, which has been reported in other balance and mobility instruments. The current subscales did not show acceptable psychometrics, which is in line with multiple recent studies favoring the use of the total score. The study also shows that the DHI is adaptable to episodic recurrent vestibulopathies. The total score shows better precision and separation of subjects in up to four strata compared to the separate construct that separate subjects into less than three strata. The measurement error smallest detectable change was found in our analysis to be 18 points, which means any change in the DHI of less than 18 points is not likely to be clinically significant. The minimal clinically important difference remains indeterminate.

Mesenchymal stem cell therapy in aqueous deficient dry eye disease

ENGLISH SUMMARY

Dry eye disease (DED) is characterized by ocular dryness, irritation and blurred vision and has a significant impact on the patient's quality of life. This condition can be particularly severe in patients with aqueous deficient dry eye disease (ADDE) due to Sjögren's syndrome (SS), an autoimmune disease that affects the lacrimal and salivary glands. Current treatments for ADDE are often limited to symptomatic relief. A literature review was conducted to explore the current surgical interventions used or tested in humans with ADDE (I). These interventions include procedures involving the eyelids and tear ducts, transplantation of amniotic membrane or salivary glands, injections around the tear ducts and cell-based injections into the lacrimal gland (LG). Each treatment has its advantages and disadvantages; however, treating dry eyes in patients with SS presents a particular challenge due to the systemic nature of the disease. Moreover, there is a need for new therapeutic options. Mesenchymal stem cells (MSCs) are a type of stem cell that have shown promise in regenerating damaged tissue and reducing inflammation in various diseases. Previous studies in animal models have suggested that MSCs could be effective in treating ADDE. Thus, this thesis aims to investigate the safety and efficacy of injecting MSCs into the LG as a treatment option for patients with ADDE secondary to SS. The study also aims to see this treatment in light of existing and novel investigational treatment options. The clinical studies conducted for this thesis are the first of their kind in humans. MSCs derived from healthy donors' adipose tissue (ASCs) were cultured in a laboratory, frozen and thawed ready for use. In the safety study, we performed the first human trial involving the administration of a single injection of ASCs into the LG of one eye in seven patients suffering from severe ADDE (II). The primary objective was to test the safety of this treatment, while the secondary objective was to assess improvements in subjective and objective signs of dry eye. The results of the trial showed no serious side effects within 4 months of follow-up after treatment. On average, there was a 40% reduction in dry eye symptoms assessed with the Ocular Surface Disease Index (OSDI) questionnaire. Additionally, in the treated eye, there was a significant decrease in tear osmolarity, an increase in tear film stability and an increase in tear production. To further investigate the efficacy of this treatment, our research group performed a clinical, randomized study aiming to compare the ASC injection into the LG with the injection of a vehicle (the excipient in which the ASCs are dissolved) and observation (no intervention) (III). The study involved 20 subjects receiving ASC injection, 20 subjects receiving vehicle injection and 14 patients being observed without intervention. The subjects were examined to assess the outcomes with a 12-month follow-up after treatment. Both intervention groups showed a significant reduction in subjective dry eye symptoms of approximately 40%. This improvement was evident at the 1-week follow-up and persisted until the 12-month follow-up. The observation group did not experience any change in OSDI score. The ASCs group exhibited a significant mean increase in non-invasive tear break-up time (NIKBUT) of 6.48 s (149%) at the four-week follow-up, which was significantly higher than that in the vehicle group (p = 0.04). Moreover, the ASCs group showed a significant increase in NIKBUT compared to that in the observation group at the 12-month follow-up (p = 0.004). In both the ASCs and vehicle group, a significant increase in Schirmer test scores at the 4-month follow-up and the 12-month follow-up was observed. In conclusion, this thesis contributes valuable findings with a new treatment option for patients with dry eye disease. Injection of ASCs into the LG was shown to be safe and to improve subjective dry eye symptoms and specifically the tear film stability in patients with ADDE due to SS. Compared to other treatment modalities of ADDE, this treatment has greater potential, as ASCs could potentially be used as an anti-inflammatory therapeutic option for managing DED of other causes as well. RESUMÉ (DANISH SUMMARY): Tørre øjne, karakteriseret ved tørhedsfornemmelse og irritation af øjnene samt sløret syn, har en betydelig indvirkning på patientens livskvalitet. Denne tilstand kan vaere saerligt alvorlig hos patienter med nedsat tåreproduktion (ADDE) som følge af Sjögrens syndrom (SS), en autoimmun sygdom, der påvirker tårekirtlerne og spytkirtlerne. Nuvaerende behandlinger for ADDE er ofte begraenset til symptomlindring. Vi gennemførte en litteraturgennemgang for at undersøge, hvilke nuvaerende kirurgiske behandlingsmetoder, der anvendes eller testes hos patienter med ADDE (I). Disse interventioner inkluderer procedurer, der involverer øjenlåg og tårekanaler, transplantation af amnionhinde eller spytkirtler, injektioner omkring tårekanalerne samt cellebaserede injektioner i tårekirtlen. Hver behandling har sine fordele og ulemper, men behandling af tørre øjne hos patienter med SS udgør en saerlig udfordring på grund af sygdommens systemiske udbredning, og der er behov for nye behandlingsmuligheder. Mesenkymale stamceller (MSCs) er en type stamcelle, der har vist lovende resultater med hensyn til at regenerere beskadiget vaev og reducere inflammation i forskellige sygdomme. Tidligere undersøgelser i dyremodeller har indikeret, at MSCs kan vaere en effektiv behandling af ADDE. Denne afhandling har til formål at undersøge sikkerheden og effekten af injektion af MSCs i tårekirtlen som en mulig behandling til patienter med ADDE som følge af SS. Afhandlingen sigter også mod at sammenligne denne behandling med andre eksisterende, kirurgiske behandlingsmuligheder af ADDE. Som led i dette projekt udførte vi de første kliniske forsøg af sin art i mennesker. MSCs fra raske donorers fedtvaev (ASCs) blev dyrket i et laboratorium, frosset ned og er optøet klar til brug. Det første mål var at teste sikkerheden ved denne behandling og sekundaert at undersøge behandlingens effekt. For at undersøge dette modtog syv forsøgspersoner med svaer ADDE én injektion med ASCs i tårekirtlen på det ene øje (II). Resultaterne af forsøget viste ingen alvorlige bivirkninger inden for fire måneders opfølgning efter behandlingen. I gennemsnit fandt vi yderligere en 40% reduktion i symptomer på tørre øjne vurderet med et spørgeskema, og en markant stigning i tåreproduktionen og af tårefilmens stabilitet i det behandlede øje. For yderligere at undersøge effekten af denne behandling udførte vi et klinisk, randomiseret forsøg med det formål at sammenligne injektion af ASCs i tårekirtlen med injektion af en kontrolopløsning (vaesken, hvor stamcellerne var opløst) og observation (ingen intervention) (III). Studiet omfattede 20 forsøgspersoner, der modtog ASC-injektion, 20 forsøgspersoner, der modtog injektion af kontrolopløsningen, og 14 forsøgspersoner i observationsgruppen. Forsøgspersonerne blev undersøgt med en opfølgningstid på 12 måneder efter behandling. Begge interventionsgrupper viste en betydelig reduktion på ca. 40% i subjektive symptomer på tørre øjne. Denne forbedring var betydelig allerede ved opfølgning efter en uge og varede ved 12 måneder efter behandling. Observationsgruppen oplevede ingen betydelig aendring i symptomer. ASCs gruppen viste desuden en signifikant stigning i tårefilmsstabiliteten (NIKBUT) på 6,48 sekunder (149%) ved opfølgning efter fire uger, hvilket var markant højere end efter injektion af kontrolopløsning (p = 0,04). Desuden viste ASCs gruppen en betydelig stigning i NIKBUT sammenlignet med observationsgruppen ved opfølgning efter 12 måneder (p = 0,004). Både injektion af ASCs og kontrolopløsning medførte en betydelig stigning i tåreproduktionen ved opfølgning fire måneder og 12 måneder efter behandling. Denne afhandling bidrager med vigtige resultater inden for en ny behandlingsmulighed af tørre øjne. Injektion af ASCs i tårekirtlen viste sig at vaere sikker, forbedrede subjektive symptomer på tørre øjne og øgede saerligt tårfilmens stabilitet hos patienter med ADDE på grund af SS. Sammenlignet med andre behandlingsmuligheder for ADDE har denne behandling vist et stort potentiale. ASCs kan muligvis også bruges som en anti-inflammatorisk behandling af tørre øjne af andre årsager i fremtiden.

Are Primary Outcomes Really Primary? An Exploratory Cross-Sectional Nationwide Web-Based Survey Study for Outcomes Reflecting Real Symptoms and Needs of Patients with Lumbar Disc Herniation

As primary outcomes differ among clinical lumbar disc herniation (LDH) studies, this study aimed to explore outcomes reflecting real-world patient experiences through an exploratory questionnaire survey. Those diagnosed with LDH having radiating leg pain in South Korea in November of 2022 (N = 500) were administered a questionnaire including basic characteristics, disease onset, symptoms and severity, priority symptoms for improvement, and important treatment factors. Outcome measures included the identification of priority symptoms and disabilities. Most common symptoms were numbness in the leg (N = 435, 87.0%) and back pain (N = 406, 81.2%); most common disabilities were discomfort in sitting (N = 323, 64.6%) and lifting (N = 318, 63.6%). The highest priority symptom was back pain (N = 242, 48.4%). A satisfactory degree of symptom improvement was a decrease of at least 3 points on the numeric rating scale. The majority of respondents preferred improvement in disability over pain (N = 270, 55.8%), a stable effect over a rapid effect (N = 391, 78.2%), and safety over treatment efficacy (N = 282, 56.4%). Safety (N = 129, 25.8%) and cost (N = 111, 22.2%) were the most important treatment factors. Improvements in back pain, leg pain, sitting, and sleeping were prioritized, and safety, stable treatment effect, and functional recovery were desired. Clinical trials for LDH should be designed to reflect this real-world patient need. Further study to examine the patients' symptoms and needs in details is needed.

Comparison of cognitive functional therapy and movement system impairment treatment in chronic low back pain patients: a randomized controlled trial

BACKGROUND

This study aimed to compare the effects of cognitive functional therapy (CFT) and movement system impairment (MSI)-based treatment on pain intensity, disability, Kinesiophobia, and gait kinetics in patients with chronic non-specific low back pain (CNSLBP).

METHODS

In a single-blind randomized clinical trial, we randomly assigned 91 patients with CNSLBP into CFT (n = 45) and MSI-based treatment (n = 46) groups. An 8-week training intervention was given to both groups. The researchers measured the primary outcome, which was pain intensity (Numeric rating scale), and the secondary outcomes, including disability (Oswestry disability index), Kinesiophobia (Tampa Kinesiophobia Scale), and vertical ground reaction force (VGRF) parameters at self-selected and faster speed (Force distributor treadmill). We evaluated patients at baseline, at the end of the 8-week intervention (post-treatment), and six months after the first treatment. We used mixed-model ANOVA to evaluate the effects of the interaction between time (baseline vs. post-treatment vs. six-month follow-up) and group (CFT vs. MSI-based treatment) on each measure.

RESULTS

CFT showed superiority over MSI-based treatment in reducing pain intensity (P < 0.001, Effect size (ES) = 2.41), ODI (P < 0.001, ES = 2.15), and Kinesiophobia (P < 0.001, ES = 2.47) at eight weeks. The CFT also produced greater improvement in VGRF parameters, at both self-selected (FPF[P < 0.001, ES = 3], SPF[P < 0.001, ES = 0.5], MSF[P < 0.001, ES = 0.67], WAR[P < 0.001, ES = 1.53], POR[P < 0.001, ES = 0.8]), and faster speed, FPF(P < 0.001, ES = 1.33, MSF(P < 0.001, ES = 0.57), WAR(P < 0.001, ES = 0.67), POR(P < 0.001, ES = 2.91)] than the MSI, except SPF(P < 0.001, ES = 0.0) at eight weeks.

CONCLUSION

This study suggests that the CFT is associated with better results in clinical and cognitive characteristics than the MSI-based treatment for CNSLBP, and the researchers maintained the treatment effects at six-month follow-up. Also, This study achieved better improvements in gait kinetics in CFT. CTF seems to be an appropriate and applicable treatment in clinical setting.

TRIAL REGISTRATION

The researchers retrospectively registered the trial 10/11/2022, at https://www.umin.ac.jp/ with identifier number (UMIN000047455).

Modic Changes of the Cervical and Lumbar Spine and Their Effect on Neck and Back Pain: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review.

OBJECTIVES

To systematically review the current literature and perform a meta-analysis on patients with cervical or lumbar spine Modic changes to determine if their baseline axial back pain and disability are comparable to patients without Modic changes.

METHODS

A systematic review of the PubMed database was conducted in accordance with PRISMA guidelines. A meta-analysis was performed to compare the mean differences in back pain, leg pain, and disability based on the presence of cervical or lumbar spine Modic changes. A subgroup analysis of the different types of Modic changes was conducted to determine if Modic type affected back pain or disability.

RESULTS

- After review of 259 articles, 17 studies were included for meta-analysis and ten studies were included for qualitative synthesis. In the lumbar spine, 10 high-quality studies analyzed Visual Analog Scale (VAS) back pain, 10 evaluated VAS leg pain, and 8 analyzed Oswestry Disability Index. VAS back pain (mean difference (MD), -.38; 95% CI, -.61 - .16) and Oswestry disability index (MD -2.52; 95% CI, -3.93 - -1.12) were significantly lower in patients without Modic changes. Modic change subtype was not associated with differences in patient-reported outcomes. Patients with cervical spine Modic changes did not experience more severe pain than those without MC.

CONCLUSIONS

Modic changes in the lumbar spine are not associated with clinically significant axial low back pain severity or patient disability. Similar to the lumbar spine, Modic changes in the cervical spine are not associated with symptom severity, but they are associated with pain duration.

Metrics of Clinically Important Changes in Total Hip Arthroplasty: A Systematic Review

BACKGROUND

Although patient-reported outcome measures (PROMs) have become a regularly used metric, there is little consensus on the methodology used to determine clinically relevant postoperative outcomes. We systematically reviewed the literature for studies that have identified metrics of clinical efficacy after total hip arthroplasty (THA) including minimal clinically important difference (MCID), patient acceptable symptom state (PASS), minimal detectable change (MDC), and substantial clinical benefit (SCB).

METHODS

A systematic review examining quantitative metrics for assessing clinical improvement with PROMs following THA was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the MEDLINE database from 2008 to 2020. Inclusion criteria included full texts, English language, primary THA with minimum 1-year follow-up, use of metrics for assessing clinical outcomes with PROMs, and primary derivations of those metrics. Sixteen studies (24,487 THA patients) met inclusion criteria and 11 different PROMs were reported.

RESULTS

MCIDs were calculated using distribution methods in 7 studies (44%), anchor methods in 2 studies (13%), and both methods in 2 studies (13%). MDC was calculated in 2 studies, PASS was reported in 1 study using anchor-based method, and SCB was calculated in 1 study using anchor-based method.

CONCLUSION

There is a lack of consistency in the literature regarding the use and interpretation of PROMs to assess patient satisfaction. MCID was the most frequently reported measure, while MDC, SCB, and PASS were used relatively infrequently. Method of derivation varied based on the PROM used; distribution method was more frequently used for MCID.

The Minimal Clinically Important Difference: A Review of Clinical Significance

BACKGROUND

The minimal clinically important difference (MCID) is a term synonymous with orthopaedic clinical research over the past decade. The term represents the smallest change in a patient-reported outcome measure that is of genuine clinical value to patients. It has been derived in a myriad of ways in existing orthopaedic literature.

PURPOSE

To describe the various modalities for deriving the MCID.

STUDY DESIGN

Narrative review; Level of evidence, 4.

METHODS

The definitions of common MCID determinations were first identified. These were then evaluated by their clinical and statistical merits and limitations.

RESULTS

There are 3 primary ways for determining the MCID: anchor-based analysis, distribution-based analysis, and sensitivity- and specificity-based analysis. Each has unique strengths and weaknesses with respect to its ability to evaluate the patient's clinical status change from baseline to posttreatment. Anchor-based analyses are inherently tied to clinical status yet lack standardization. Distribution-based analyses are the opposite, with strong foundations in statistics, yet they fail to adequately address the clinical status change. Sensitivity and specificity analyses offer a compromise of the other methodologies but still rely on a somewhat arbitrarily defined global transition question.

CONCLUSION

This current concepts review demonstrates the need for (1) better standardization in the establishment of MCIDs for orthopaedic patient-reported outcome measures and (2) better study design-namely, until a universally accepted MCID derivation exists, studies attempting to derive the MCID should utilize the anchor-based within-cohort design based on Food and Drug Administration recommendations. Ideally, large studies reporting the MCID as an outcome will also derive the value for their populations. It is important to consider that there may be reasonable replacements for current derivations of the MCID. As such, future research should consider an alternative threshold score with a more universal method of derivation.

The effectiveness and safety of repetitive transcranial magnetic stimulation on spasticity after upper motor neuron injury: A systematic review and meta-analysis

To systematically evaluate the effectiveness and safety of repetitive transcranial magnetic stimulation (rTMS) on spasticity after upper motor neuron (UMN) injury. Eight electronic databases were searched from inception to August 6, 2022. Randomized controlled trials (RCTs) investigating the effectiveness and safety of rTMS on spasticity after UMN injury were retrieved. Two reviewers independently screened studies, extracted data, and assessed the risk of bias. Review Manager 5.3 and Stata 14.0 software were used to synthesize data. The certainty of the evidence was appraised with the Grade of Recommendation, Assessment, Development and Evaluation tool. Forty-two studies with a total of 2,108 patients were included. The results of meta-analysis revealed that, compared with control group, rTMS could significantly decrease scores of the Modified Ashworth Scale (MAS) in patients with UMN injury. The subgroup analysis discovered that rTMS effectively decreased the MAS scores in patients with stroke. Meanwhile, rTMS treatment > 10 sessions has better effect and rTMS could decrease the MAS scores of upper limb. Thirty-three patients complained of twitching facial muscles, headache and dizziness, etc. In summary, rTMS could be recommended as an effective and safe therapy to relieve spasticity in patients with UMN injury. However, due to high heterogeneity and limited RCTs, this conclusion should be treated with caution.

Preoperative Patient-Reported Outcome Measure Thresholds Should Not be Used for Indicating Total Knee Arthroplasty

BACKGROUND

While Medicare requires patient-reported outcome measures (PROMs) for many quality programs, some commercial insurers are requiring preoperative PROMs when determining eligibility for total knee arthroplasty (TKA). Concerns exist that these data may be used to deny TKA to patients above a specific PROM score, but the optimal threshold is unknown. We aimed to evaluate TKA outcomes based on theoretical PROM thresholds.

METHODS

We retrospectively analyzed 25,246 consecutive primary TKA patients from 2016 to 2019. Hypothesized preoperative knee injury and osteoarthritis outcome score for joint replacement cutoffs of 40, 50, 60, and 70 points were used. Preoperative scores below each threshold were considered "approved" surgery. Preoperative scores above each threshold were considered "denied" surgery. In-hospital complications, 90-day readmissions, and discharge disposition were evaluated. One-year minimum clinically important difference (MCID) achievement was calculated using previously validated anchor-based methods.

RESULTS

For "denied" patients below thresholds 40, 50, 60, and 70 points, 1-year MCID achievement was 88.3%, 85.9%, 79.6%, and 77%, respectively. In-hospital complication rates for approved patients were 2.2%, 2.3%, 2.1%, and 2.1%, while 90-day readmission rates were 4.6%, 4.5%, 4.3%, and 4.3%, respectively. Approved patients had higher MCID achievement rates (P < .001) for all thresholds but higher nonhome discharge rates than denied patients for thresholds 40 (P < .001), 50 (P = .002), and 60 (P = .024). Approved and denied patients had similar in-hospital complication and 90-day readmission rates.

CONCLUSION

Most patients achieved MCID at all theoretical PROMs thresholds with low complication and readmission rates. Setting preoperative PROM thresholds for TKA eligibility can help optimize patient improvement, but such a policy can create access to care barriers for some patients who would otherwise benefit from a TKA.

The Appropriateness of Preoperative Patient Reported Outcome Measures as an Indication for Total Hip Arthroplasty

BACKGROUND

While Medicare requires patient-reported outcome measures (PROMs) for many quality programs, some commercial insurers have begun requiring preoperative PROMs when determining patient eligibility for total hip arthroplasty (THA). Concerns exist these data may be used to deny THA to patients above a specific PROM score, but the optimal threshold is unknown. We aimed to evaluate outcomes following THA based on theoretical PROM thresholds.

METHODS

We retrospectively analyzed 18,006 consecutive primary THA patients from 2016-2019. Hypothesized preoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS-JR) cutoffs of 40, 50, 60, and 70 points were used. Preoperative scores below each threshold were considered "approved" surgery. Preoperative scores above each threshold were considered "denied" surgery. In-hospital complications, 90-day readmissions, and discharge disposition were evaluated. HOOS-JR scores were collected preoperatively and 1-year postoperatively. Minimum clinically important difference (MCID) achievement was calculated using previously validated anchor-based methods.

RESULTS

Using preoperative HOOS-JR thresholds of 40, 50, 60, and 70 points, the percentage of patients who would have been denied surgery was 70.4%, 43.2%, 20.3%, and 8.3%, respectively. For these denied patients, 1-year MCID achievement was 75.9%, 69.0%, 59.1%, and 42.1%, respectively. In-hospital complication rates for approved patients were 3.3%, 3.0%, 2.8%, and 2.7%, while 90-day readmission rates were 5.1%, 4.4%, 4.2%, and 4.1%, respectively. Approved patients had higher MCID achievement (P < .001) but higher nonhome discharge (P = .01) and 90-day readmissions rates (P = .036) than denied patients.

CONCLUSION

Most patients achieved MCID at all theoretical PROM thresholds with low complication and readmission rates. Setting preoperative PROM thresholds for THA eligibility did not guarantee clinically successful outcomes.

The SNAP Trial: 2-Year Results of a Double-Blind Multicenter Randomized Controlled Trial of a Silicon Nitride Versus a PEEK Cage in Patients After Lumbar Fusion Surgery

STUDY DESIGN

Randomized controlled trial.

OBJECTIVES

Lumbar interbody fusion with cages is performed to provide vertebral stability, restore alignment, and maintain disc and foraminal height. Polyetheretherketone (PEEK) is commonly used. Silicon nitride (Si₃N₄) is an alternative material with good osteointegrative properties. This study was designed to assess if Si₃N₄ cages perform similar to PEEK.

METHODS

A non-inferiority double-blind multicenter RCT was designed. Patients presenting with chronic low-back pain with or without leg pain were included. Single- or double-level instrumented transforaminal lumbar interbody fusion (TLIF) using an oblique PEEK or Si₃N₄ cage was performed. The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ). The non-inferiority margin for the RMDQ was 2.6 points on a scale of 24. Secondary outcomes included the Oswestry Disability Questionnaire (ODI), Visual Analogue Scales (VAS), SF-36 Physical Function, patient and surgeon Likert scores, radiographic evaluations for subsidence, segmental motion, and fusion. Follow-up was planned at 3, 6, 12, and 24-months.

RESULTS

Ninety-two patients were randomized (i.e. 48 to PEEK and 44 to Si₃N₄). Both groups showed good clinical improvements on the RMDQ scores of up to 5-8 points during follow-up. No statistically significant differences were observed in clinical and radiographic outcomes. Mean operative time and blood loss were statistically significantly higher for the Si₃N₄ cohort. Although not statistically significant, there was a higher incidence of complications and revisions associated with the Si₃N₄ cage.

CONCLUSIONS

There was insufficient evidence to conclude that Si₃N₄ was non-inferior to PEEK.

Revisiting the Concept of Minimal Detectable Change for Patient-Reported Outcome Measures

Interpreting change is a requisite component of clinical decision making for physical therapists. Physical therapists often interpret change using minimal detectable change (MDC) values. Current MDC formulas are informed by classical test theory and calculated with group-level error data. This approach assumes that measurement error is the same across a measure's scale and confines the MDC value to the sample characteristics of the study. Alternatively, an item response theory (IRT) approach calculates separate estimates of measurement error for different locations on a measure's scale. This generates a conditional measurement error for someone with a low, middle, or high score. Error estimates at the measure-level can then be used to determine a conditional MDC (cMDC) value for individual patients based on their unique pre- and post-score combination. cMDC values can supply clinicians with a means for using individual score data to interpret change scores while providing a personalized approach that should lower the threshold for change compared with the MDC and enhance the precision of care decisions by preventing misclassification of patients. The purpose of this Perspective is to present how IRT can address the limitations of MDCs for informing clinical practice. This Perspective demonstrates how cMDC values can be generated from item-level psychometrics derived from an IRT model using the patient-reported Activities-specific Balance Scale (ABC) commonly used in stroke rehabilitation and also illustrates how the cMDC compares to the MDC when accounting for changes in measurement error across a scale. Theoretical patient examples highlight how reliance on the MDC value can result in misclassification of patient change and how cMDC values can help prevent this from occurring. This personalized approach for interpreting change can be used by physical therapists to enhance the precision of care decisions.

All MCIDs Are Wrong, But Some May be Useful

OBJECTIVE

To demonstrate how to apply a baseline-adjusted receiver operator characteristic curve (AROC) analysis for minimum clinically important differences (MCIDs) in an empirical data set and discuss new insights relating to MCIDs.

DESIGN

Retrospective study.

METHODS

This study includes data from 999 active-duty military service patients enrolled in the United States Military Health System's Military Orthopedics Tracking Injuries and Outcomes Network. Anchored MCIDs were calculated using the standard receiver operator characteristic analysis and the AROC analysis for the Patient-Reported Outcome Measure Information System (PROMIS) Pain Interference and Defense and Veterans Pain Rating Scale (DVPRS). Point estimates where confidence intervals (CIs) crossed the 0.5 identity line on the area-under-the-curve (AUC) analysis were considered statistically invalid. MCID estimates where CIs crossed 0 were considered theoretically invalid.

RESULTS

In applying an AROC analysis, the region of AUC and MCID validity for the PROMIS Pain Interference score exists when the baseline score is greater than 61.0 but less than 72.3. For DVPRS, the region of MCID validity is when the baseline score is greater than 5.9 but less than 7.9.

CONCLUSION

Baseline values influence not only the MCID but also the accuracy of the MCID. MCIDs are statistically and theoretically valid for only a discrete range of baseline scores. Our findings suggest that the MCID may be too flawed a construct to accurately benchmark treatment outcomes. J Orthop Sports Phys Ther 2022;52(6):401-407. doi:10.2519/jospt.2022.11193.

Determining the minimal important differences in the RQLQ score with grass and tree allergy immunotherapy versus placebo in adults with moderate-to-severe allergy

Background

Pollen from grasses and trees can trigger allergic rhinitis (AR), where the symptoms and associated consequences can negatively affect quality of life (QoL). The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) is frequently used in clinical trials of AR to assess QoL. To help interpret RQLQ data, the minimal important difference (MID) can be used to assess whether a mean difference in QoL between treatment groups is clinically meaningful. In seasonal allergy, an MID differs according to the allergen, pollen exposure, symptom severity, patient age and treatment; the same MID cannot be applied to all scenarios.

Methods

Using data from four Phase III clinical trials of SQ sublingual immunotherapy‐tablets in adults with moderate‐to‐severe allergy, between‐group MIDs were derived for the RQLQ in grass pollen allergy (during the peak [n = 501] and entire [n = 514] pollen seasons), and in tree pollen allergy (during the birch [n = 516] and tree [n = 518] pollen seasons), using anchor‐based methodology, supported by distribution‐based methods.

Results

For grass pollen allergy, anchor‐based derived between‐group MIDs were 0.22 for the entire pollen season (n = 343) and 0.10 for the peak pollen season (n = 335). For tree pollen allergy, anchor‐based derived between‐group MIDs were 0.26 for the tree pollen season (n = 306) and 0.16 for the birch pollen season (n = 305) (representative of peak season). Distribution‐based derived MIDs were supportive of the anchor‐based values.

Conclusions

This analysis has derived between‐group MIDs specific to the trial populations evaluated and to the conditions under which the data were obtained, and highlights the need for a range of MIDs to reflect the unique nature of seasonal allergic disease.

Assessment of Low Back Pain: Reliability and Minimal Detectable Change of the Brief Pain Inventory

IMPORTANCE

The Brief Pain Inventory (BPI) is one of the most widely used measures to assess pain and related impacts among patients with low back pain (LBP). However, its test-retest reliability and minimal detectable change (MDC) have rarely been examined in patients with LBP, interfering with its utility.

OBJECTIVE

To investigate the test-retest reliability and MDC of the BPI among patients with LBP.

DESIGN

Repeated assessments design with a 1-wk interval.

SETTING

Department of Physical Medicine and Rehabilitation in a hospital in Taiwan.

PARTICIPANTS

Fifty-four patients with stable LBP conditions.

OUTCOMES AND MEASURES

The BPI has two subscales-Intensity and Interference-that assess pain intensity and pain interference, respectively. Their test-retest reliability was examined using the intraclass correlation coefficient (ICC), and MDCs were calculated.

RESULTS

The ICCs of the Intensity and Interference subscales were .62 and .76, respectively. The MDC values for the two subscales were 2.57 and 2.34, respectively. For the four Intensity items, the average-pain score had a higher ICC (.60) than scores on the other items (worst, least, and current pain, which had ICCs of about .40).

CONCLUSIONS AND RELEVANCE

The results suggest that although the BPI is a commonly used measure of pain intensity and pain interference among patients with LBP, caution should be exercised in interpreting the Intensity subscale score and its item scores. What This Article Adds: The BPI is widely used to assess pain and related impacts on daily occupation and functioning among patients with LBP. This study provides information regarding its test-retest reliability. Moreover, the MDC values provide clinicians and researchers with the thresholds for determining real improvement (beyond random measurement error).

The substantial clinical benefit of comprehensively considering low back pain and radiating pain caused by lumbar intervertebral disc herniation

BACKGROUND

Patients with lumbar disc herniation (LDH) may experience low back pain (LBP) and radiating pain (RP). Currently, there is no substantial clinical benefit (SCB) of assessing both LBP and RP due to LDH.

OBJECTIVE

To determine enhanced SCB values by simultaneously assessing LBP and RP.

METHODS

We retrospectively evaluated hospitalized LDH patients with concomitant LBP and RP between June 1, 2012, and May 31, 2013, and determined the numeric rating scale (NRS) and Oswestry Disability Index (ODI) scores at admission and discharge. Furthermore, the area under the receiver operating characteristic curve (AUC) was computed to assess diagnostic accuracy.

RESULTS

SCB as per NRS for both LBP and RP was -2.50 in the 186 enrolled patients (AUC: 0.699 and 0.704, respectively). SCB as per ODI was -18.78 (AUC: 0.771). SCB for the mean of the two NRS scores for LBP and RP was -2.75 (AUC: 0.757). SCB for NRS score with a larger change in LBP and RP was -3.50 (AUC: 0.767).

CONCLUSIONS

SCB may be determined by comprehensively considering LBP and RP and choosing the mean NRS or NRS score with a large change.

Comparison of Mid- to Long-term Follow-up of Patient-reported Outcomes Measures After Single-level Lumbar Total Disc Arthroplasty, Multi-level Lumbar Total Disc Arthroplasty, and the Lumbar Hybrid Procedure for the Treatment of Degenerative Disc Disease

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim of this article is to compare the mid- to long-term patient-reported outcome measures (PROMs) between single-level total disc arthroplasty (TDA), multi-level TDA, and hybrid constructs (combination of TDA and anterior lumbar interbody fusion [ALIF] across multiple levels) for symptomatic degenerative disc disease (DDD).

SUMMARY OF BACKGROUND DATA

The treatment of single-level DDD is well documented using TDA. However, there is still a paucity of published evidence regarding long-term outcomes on multi-level TDA and hybrid constructs for the treatment of multi-level DDD, as well as lack of long-term comparisons regarding treatment of single-level DDD and multi-level DDD.

METHODS

A total of 950 patients underwent surgery for single-level or multi-level DDD between July 1998 and February 2012 with single-level TDA (n = 211), multi-level TDA (n = 122), or hybrid construct (n = 617). Visual Analog Score for the back (VAS-B) and leg (VAS-L) were recorded, along with the Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ).

RESULTS

All PROMs in all groups showed statistically and clinically significant improvements (P < 0.005) in pain and function that is well above the corresponding minimum clinically important difference (MCID) and exceeds literature thresholds for substantial clinical benefit (SCB). Unadjusted analyses show that there were no statistically significant differences in the change scores between the surgery groups for VAS back and leg pain, and RMDQ up to 8 years' follow-up. Adjusted analyses showed the ODI improvement score for the single group was 2.2 points better (95% confidence interval [CI]: 0.6-3.9, P = 0.009) than in the hybrid group. The RMDQ change score was better in the hybrid group than in the multi-level group by 1.1 points (95% CI: 0.4-1.9, P = 0.003) at 6 months and a further 0.4 point at 2 years (95% CI: 0.1-0.8, P = 0.011).

CONCLUSION

In the setting of meticulous preoperative evaluation in establishing a precision diagnosis, clinically and statistically equivalent results can be achieved when treating symptomatic DDD through single-level TDA, multi-level TDA, and hybrid constructs. These results are sustained at mid- to long-term follow-up.Level of Evidence: 3.

Pulsed electromagnetic fields may be effective for the management of primary osteoporosis: a systematic review and meta-analysis

Little is known about the effect of pulsed electromagnetic fields (PEMFs) as an option for preventing osteoporosis. This study sought to investigate the effectiveness of PEMFs for the management of primary osteoporosis in older adults. We searched databases from the inception to date to target trials examining the effects of PEMFs compared to placebo or sham or other agents for the management of primary osteoporosis for a meta-analysis using random effects model. Eight trials including 411 participants were included. PEMFs was non-inferior to conventional pharmacological agents and exercise respectively in preventing the decline of Bone Mineral Density (BMD) at the lumbar (MD 8.76; CI -9.64 to 27.16 and MD 1.33; CI -2.73 to 5.39) and femur neck (MD 0.04; CI -1.09 to 1.16 and MD 1.50; CI -0.26 to 3.26), and significantly improving balance function measured by Berg Balance Scale (BBS) (MD 0.91; CI 0.32 to 1.49) and Timed Up and Go test (MD -3.61; CI -6.37 to -0.85), directly after intervention. The similar trends were observed in BMD and BBS at 12- and 24-weeks follow-up from baseline. PEMFs had positive effects non-inferior to first-line treatment on BMD and better over placebo on balance function in older adults with primary osteoporosis, but with moderate to very low certainty evidence and short-term follow-ups. There is a need for high-quality randomised controlled trials evaluating PEMFs for the management of primary osteoporosis.

Responder analysis for neuropathic impairment and quality-of-life assessment in patients with hereditary transthyretin amyloidosis with polyneuropathy in the NEURO-TTR study

OBJECTIVE

Hereditary transthyretin amyloidosis with polyneuropathy (ATTRv-PN) is a rare disease characterized by rapid neuropathic progression. In pivotal studies of gene-silencing treatments, the modified Neuropathy Impairment Score + 7 tests (mNIS + 7) and Norfolk-Quality of Life (QOL)-Diabetic Neuropathy (DN) questionnaire assessed treatment impact on neuropathic progression. Establishing responder definition (RD) thresholds for these measures would enable evaluation of clinically meaningful treatment benefit.

METHODS

mNIS + 7 and Norfolk-QOL-DN were administered at baseline and week 65 to 165 adults with ATTRv-PN receiving inotersen (n = 106) or placebo (n = 59) in the NEURO-TTR study. Anchor-based approaches for estimating RD thresholds were used for Norfolk QOL-DN, while distribution-based approaches were used for both measures. Responders were patients with a score change < RD, indicating improvement or stabilization (i.e., no clinically meaningful progression). Odds ratios (ORs) and Fisher's exact tests compared proportions of responders by treatment.

RESULTS

The mean RD estimates were 12.2 points and 8.8 points for mNIS + 7 and Norfolk QOL-DN, respectively. The proportions of patients whose change in score indicated improvement or stabilization were statistically significantly larger for inotersen than placebo for all estimated RD thresholds for mNIS + 7 (64-86% responders for inotersen vs. 27-46% for placebo, ORs = 3.8-7.2, ps < 0.001) and Norfolk QOL-DN (66-81% vs. 35-56%, ORs = 2.4-3.6, ps < 0.05).

DISCUSSION

Establishing RD thresholds for these instruments enables evaluation of clinically relevant and individual-level treatment benefit on neuropathic progression. Across RDs estimated using multiple methods, a higher proportion of patients receiving inotersen than placebo showed improved or stabilized neuropathic progression at week 65.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01737398; Date of registration: November 29, 2012.

Rasch analysis of The Shoulder Pain and Disability Index (SPADI) in a postrepair rotator cuff sample

STUDY DESIGN

Clinical measurement study: Level of evidence (N/A) INTRODUCTION: The Shoulder Pain and Disability Index (SPADI) is a self-reported outcome measure of pain and disability related to shoulder pathology. In comparison to Classical Test Theory (CTT), Rasch analysis offers a more rigorous examination of the measurement properties of a scale.

PURPOSE OF THE STUDY

This study utilizes Rasch analysis to evaluate the psychometric properties of the SPADI to propose potential modifications and avenues for future investigation.

METHODS

SPADI scores (n = 212) from participants one-year post rotator cuff repair were collected from an outpatient specialty clinic. Fit to the Rasch model, unidimensionality of the subscales, and areas of bias were evaluated.

RESULTS

Both the pain and disability subscales satisfied the requirements of the Rasch model with very minimal modifications and demonstrated unidimensionality. The person separation index was found to be high (P > .80), indicating reliability and internal consistency. Sex and the affected dominant side influenced how people scored on the SPADI (Differential item functioning (DIF)).

CONCLUSIONS

The findings suggest some patients in our sample have difficulty discriminating between item responses, particularly within the middle of the scale. Rasch analysis supports the clinical measurement properties of consistency and reliability, previously determined by CTT methods.

Effectiveness of App-Delivered, Tailored Self-management Support for Adults With Lower Back Pain-Related Disability: A selfBACK Randomized Clinical Trial

IMPORTANCE

Lower back pain (LBP) is a prevalent and challenging condition in primary care. The effectiveness of an individually tailored self-management support tool delivered via a smartphone app has not been rigorously tested.

OBJECTIVE

To investigate the effectiveness of selfBACK, an evidence-based, individually tailored self-management support system delivered through an app as an adjunct to usual care for adults with LBP-related disability.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial with an intention-to-treat data analysis enrolled eligible individuals who sought care for LBP in a primary care or an outpatient spine clinic in Denmark and Norway from March 8 to December 14, 2019. Participants were 18 years or older, had nonspecific LBP, scored 6 points or higher on the Roland-Morris Disability Questionnaire (RMDQ), and had a smartphone and access to email.

INTERVENTIONS

The selfBACK app provided weekly recommendations for physical activity, strength and flexibility exercises, and daily educational messages. Self-management recommendations were tailored to participant characteristics and symptoms. Usual care included advice or treatment offered to participants by their clinician.

MAIN OUTCOMES AND MEASURES

Primary outcome was the mean difference in RMDQ scores between the intervention group and control group at 3 months. Secondary outcomes included average and worst LBP intensity levels in the preceding week as measured on the numerical rating scale, ability to cope as assessed with the Pain Self-Efficacy Questionnaire, fear-avoidance belief as assessed by the Fear-Avoidance Beliefs Questionnaire, cognitive and emotional representations of illness as assessed by the Brief Illness Perception Questionnaire, health-related quality of life as assessed by the EuroQol-5 Dimension questionnaire, physical activity level as assessed by the Saltin-Grimby Physical Activity Level Scale, and overall improvement as assessed by the Global Perceived Effect scale. Outcomes were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months.

RESULTS

A total of 461 participants were included in the analysis; the population had a mean [SD] age of 47.5 [14.7] years and included 255 women (55%). Of these participants, 232 were randomized to the intervention group and 229 to the control group. By the 3-month follow-up, 399 participants (87%) had completed the trial. The adjusted mean difference in RMDQ score between the 2 groups at 3 months was 0.79 (95% CI, 0.06-1.51; P = .03), favoring the selfBACK intervention. The percentage of participants who reported a score improvement of at least 4 points on the RMDQ was 52% in the intervention group vs 39% in the control group (adjusted odds ratio, 1.76; 95% CI, 1.15-2.70; P = .01).

CONCLUSIONS AND RELEVANCE

Among adults who sought care for LBP in a primary care or an outpatient spine clinic, those who used the selfBACK system as an adjunct to usual care had reduced pain-related disability at 3 months. The improvement in pain-related disability was small and of uncertain clinical significance. Process evaluation may provide insights into refining the selfBACK app to increase its effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03798288.

How much improvement can satisfy patients? Exploring patients' satisfaction 3 years after total knee arthroplasty

Background

Despite the innovations in total knee arthroplasty (TKA), there is still a subset of patients who do not acquire significant relief or expected satisfaction after primary TKA. However, this subgroup of patients still gains improvements more or less in terms of objective or quantified assessments after the procedure. The purpose of our study is to explore the factors that correlate with patients’ satisfaction and identify minimal clinically important difference (MCID) and minimum important change (MIC) in clinical parameters.

Methods

We conducted a retrospective study of 161 patients diagnosed with osteoarthritis who underwent unilateral total knee arthroplasty from January 2017 to December 2017. We collected the following parameters: body mass index (BMI), duration of disease, education level, depression state, preoperative flexion contracture angle of knee, HSS scores, 11-point NRS scores, and radiological parameters (preoperative minimal joint space width and varus angle of knee). The satisfaction was graded by self-reported scores in percentage (0–100).

Results

We revealed that 80.8% of patients were satisfied 3 years overall after primary TKA. HSS score change, NRS-Walking score change, age, and pre-mJSW showed significant difference between satisfied and dissatisfied group. The varus angle change revealed statistical significance according to the levels of satisfaction. Simple linear regression identified the MCID for HSS score to be 5.41 and for the NRS-Walking to be 1.24. The receiver operating characteristics (ROC) curve identified the MIC for HSS score to be 25.5 and for the NRS-Walking score to be 6.5.

Conclusions

In summary, we identified several factors that correlated with patients’ satisfaction independently after TKA in a long term. In addition, we revealed the minimal clinically important difference (MCID) and minimum important change (MIC) for HSS and NRS score in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02514-2.

Sensitivity to Change and Responsiveness of the Original and the Shortened Version of the Community Balance & Mobility Scale for Young Seniors

OBJECTIVE

To examine sensitivity to change and responsiveness of the Community Balance & Mobility Scale (CBM) and shortened CBM (s-CBM) DESIGN: Secondary analysis using data of a randomized controlled trial SETTING: General community PARTICIPANTS: Community-dwelling seniors aged 61-70 years INTERVENTION: Participants underwent 12 months of exercise intervention MAIN OUTCOME MEASURES: CBM and s-CBM. Sensitivity to change was assessed using standardized response mean (SRM), and paired t-tests as appropriate. Responsiveness was assessed using two minimal important difference (MID) estimates. Analyses were conducted for the full sample and for the subgroups 'high-balance' and 'low-balance', divided by median split.

RESULTS

Young community-dwelling seniors (n=155, 66.2±2.5) were recruited. Inferential statistics revealed a significant CBM (p<0.001) and s-CBM (p<0.001) improvement within the full sample and the subgroups (high-balance: p=0.001, p=0.019; low-balance: p<0.001, p<0.001). CBM and s-CBM were moderately sensitive to change (SRM: 0.48 vs. 0.38) within the full sample. In the high-balance subgroup, moderate SRM values (0.70) were found for the CBM, small values for the s-CBM (0.29). In the low-balance subgroup, moderate SRM values were found for the CBM (0.67), high values for the s-CBM (0.80). For the full sample, CBM and s-CBM exceeded the lower, but not the higher MID value. In the high-balance subgroup, the CBM exceeded both MID values, the s-CBM only the lower. In the low-balance subgroup, CBM and s-CBM exceeded both MID values.

CONCLUSIONS

The CBM is a suitable tool to detect intervention-related changes of balance and mobility in young, high-performing seniors. Both versions of the CBM scale show good sensitivity to change and responsiveness, particularly in young seniors with low-balance.

Investigating the effects of volar wrist cock-up splint and dorsal lock wrist hand orthosis in reducing signs of carpal tunnel syndrome

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy presenting with sharp pain, parenthesis, dysfunction of the hand in coordination and gripping. Splinting is the most common conservative intervention to improve pain and enological symptom of this Syndrome (CTS). With regard to the importance of these interventions and controversies about different designs of splints, the aim of this study was to compare the therapeutic effects of volar wrist cock-up orthosis and dorsal lock wrist hand orthosis on pain, sensory and motor latency in carpal tunnel syndrome. Methods: In this Randomized controlled trial study, 30 patients diagnosed with mild to moderate CTS were recruited. The subjects were randomly divided into two equal groups. Both groups received one form of splints for three weeks. Before receiving the splints, Electromyography (EMG) and Visual analog scale (VAS) were performed. Then, two different designs of splints were used for a period of three weeks. After that, EMG and Numerical Rating Scale (NRS-11) were repeated to reveal the effects of splints on reducing pain, sensory and motor latency in CTS. Independent t and paired t-tests were done uding SPSS software version 19.0. P-value was set at 0.05. Results: All the variables in both groups showed significant improvement. The NRS-11 test was significantly improved in the dorsal lock wrist hand orthosis group (p<0.05). Conclusion: This study showed that the use of the dorsal lock wrist hand orthosis for about three weeks was significantly improved pain and neurological symptoms of patients with CTS because of maintaining the wrist in the neutral position. Knowing this fact helps us to design and make a less cumbersome and restrictive splint with an accurate position for the wrist and distal joints.

Establishing Clinically Significant Patient-reported Outcomes for Diverticular Disease

BACKGROUND

Diverticular disease can undermine health-related quality of life. The diverticulitis quality of life (DV-QOL) instrument was designed and validated to measure patient-reported burden of diverticular disease. However, values reflecting meaningful improvement (i.e., minimal clinically important difference [MCID]) and the patient acceptable symptom state (PASS) have yet to be established. We sought to establish the MCID and PASS of the DV-QOL and describe the characteristics of those with DV-QOL above the PASS threshold.

MATERIALS AND METHODS

We performed a prospective cohort study of adults with diverticular disease from seven centers in Washington and California (2016-2018). Patients were surveyed at baseline, then quarterly up to 30 mo. To determine the MCID and PASS for DV-QOL, we applied various previously established distribution- and anchor-based approaches and compared the resulting values.

RESULTS

The study included 177 patients (mean age 57 y, 43% women). A PASS threshold of 3.2/10 distinguished between those with and without health-related quality of life-impacting diverticulitis with acceptable accuracy (area under the curve 0.76). A change of 2.2 points in the DV-QOL was the most appropriate MCID: above the distribution-based MCIDs and corresponding to patient perception of importance of change (AUC 0.70). Patients with DV-QOL ≥ PASS were more often men, younger, had Medicaid, had more serious episodes of diverticulitis, and had an occupational degree or high-school education or less.

CONCLUSIONS

Our study is the first to define MCID and PASS for DV-QOL. These thresholds are critical for measuring the impact of diverticular disease and the evaluation of treatment effectiveness.

Responsiveness and Minimal Clinically Important Difference of the Five Times Sit-to-Stand Test in Patients with Stroke

This study aimed to analyze the responsiveness of the 5STS test among stroke patients and to estimate the MCIDs (minimal clinically important differences) for different severity levels of community ambulation and stages of recovery. The 5STS and comparator instruments (gait speed and Functional Ambulatory Category (FAC)) were evaluated at baseline. These measures were repeated at 4 (Stage 1) and 8 weeks (Stage 2), together with the Global Rating of Change (GROC). The MCIDs were calculated with two anchor-based methods using the GROC as the external criterion. Responsiveness to change for the 5STS was estimated analyzing the correlation with changes in the two comparator instruments and their capacity to discriminate improvement. For the 5STS test, while the MCIDs of the limited community ambulators were similar in the two stages (around 3 s), those of the household ambulators decreased from 1.9 s to 0.72 s. Spearman’s rho coefficients showed an acceptable correlation between changes in 5STS and changes for both the FAC and gait speed changes in both stages of recovery. Our study revealed that the 5STS is responsive to functional changes in patients with stroke and that their degree of severity and stage of recovery influence the MCID values of the 5STS.

Efficacy of abdominal trunk muscles-strengthening exercise using an innovative device in treating chronic low back pain: a controlled clinical trial

Exercise is the most common conservative intervention for chronic low back pain (CLBP). We have developed an innovative exercise device for the abdominal trunk muscles that also measures muscle strength in a sitting position. The device, which is easy for patients with CLBP to use, allows for lumbar stabilization exercise under pressure. This study aimed to examine the efficacy of abdominal trunk muscle strengthening using the device in improving CLBP. We conducted a two-group non-randomized controlled clinical trial. CLBP patients were allocated into two groups. The strengthening group underwent a 12-week exercise program that included abdominal trunk muscle strengthening using our device and stretching exercises, while the control group received a 12-week stretching exercise program. The outcome measures included the improvement of the abdominal trunk muscle strength measured by the device, pain intensity of CLBP, physical function, and quality of life (QOL). A total of 40 participants (20 in each group) were analyzed. The strengthening group showed better improvement in the abdominal trunk muscle strength, CLBP, physical function, and QOL than in the control group. In conclusion, the strengthening exercise using the device with easy stretching was effective in improving the strength of the abdominal trunk muscles, pain intensity of CLBP, physical function, and QOL.

Determining the Minimal Clinical Important Difference for Medication Quantification Scale III and Morphine Milligram Equivalents in Patients with Failed Back Surgery Syndrome

The Medication Quantification Scale III (MQS) is a tool to represent the negative impact of medication. A reduction in medication can serve as an indicator to evaluate treatment success. However, no cut-off value has yet been determined to evaluate whether a decrease in medication is clinically relevant. Therefore, the objective is to estimate the thresholds for the MQS and morphine milligram equivalents (MMEs) that best identify a clinically relevant important improvement for patients. Data from the Discover registry, in which patients with failed back surgery syndrome were treated with high-dose spinal cord stimulation, were used. Patient satisfaction was utilized to evaluate a clinically important outcome 12 months after stimulation. Anchor-based and distribution-based methods were applied to determine the minimal clinical important difference (MCID). Distribution-based methods revealed a value of 4.28 for the MQS and 33.61 for the MME as MCID. Anchor-based methods indicated a percentage change score of 41.2% for the MQS and 28.2% for the MME or an absolute change score of 4.72 for the MQS and 22.65 for the MME. For assessing a treatment outcome, we recommend using the percentage change score, which better reflects a clinically important outcome and is not severely influenced by high medication intake at baseline.

Effects of brief self-exercise education on the management of chronic low back pain: A community-based, randomized, parallel-group pragmatic trial

OBJECTIVE

This study aimed to develop and assess additional effects of brief self-exercise education (brief-See) for individuals with chronic low back pain (CLBP). The brief-See comprised 100-minute consultation, individualized self-exercise program, and direct short teaching.

METHODS

We conducted a 6-month, community-based, randomized, parallel-group trial in a community setting, and allocated into a brief-See or material-based education alone. Pain intensity (NRS, numeric rating scale), functional limitation (RDQ, Roland-Morris disability questionnaire), self-efficacy (PSEQ, pain self-efficacy questionnaire), and quality of life (EQ-5D, European quality of life-5 dimensions) were evaluated at 4, 12, and 24 weeks after the initial consultation.

RESULTS

The brief-See did not show additional improvement over material-based education on the NRS, but it did on the RDQ, PSEQ, and EQ-5D; the estimated mean group differences in changes from the baseline were -2.1 (-3.5 to -0.7, p = .005) on the RDQ, 6.9 (1.7-12.1, p = .010) on the PSEQ, and 0.07 (0.02-0.12, p = .004) on the EQ-5D.

CONCLUSION

The 100 minutes' education program could be more acceptable, and restores functional limitation, self-efficacy, and quality of life in addition to the effects of material-based education. This has the potential to contribute to the management of CLBP in a community.

Two-year results of a double-blind multicenter randomized controlled non-inferiority trial of polyetheretherketone (PEEK) versus silicon nitride spinal fusion cages in patients with symptomatic degenerative lumbar disc disorders

Background

During lumbar spinal fusion, spacer cages are implanted to provide vertebral stability, restore sagittal alignment, and maintain disc and foraminal height. Polyetheretherketone (PEEK) is commonly used by most spine surgeons. Silicon nitride (Si₃N₄) is a less well-known alternative although it was first used as a spacer in lumbar fusion over 30 years ago. The present study was designed to see if Si₃N₄ cages would perform similarly to PEEK in a randomized controlled trial.

Methods

A non-inferiority multicenter 100-patient study was designed where both the observer and patient were blinded. Single- or double-level transforaminal lumbar interbody fusion with pedicle screw fixation using an oblique PEEK or Si₃N₄ cage was performed. The primary non-inferiority outcome was the Roland-Morris Disability Questionnaire (RMDQ). Secondary measures included the Oswestry Disability Questionnaire, Visual Analogue Scales (VAS) for back and leg pain, SF-36 Physical and Mental Function indices, patient and surgeon Likert scores on perceived recovery, and X-ray and CT radiological evaluations for subsidence, segmental motion, and fusion. Follow-up evaluations occurred at 3, 6, 12, and 24 months.

Results

After exclusions for protocol violations and canceled surgeries, 92 patients were randomized (i.e., 48 for PEEK and 44 for Si₃N₄). There were no differences in baseline demographics, pre-operative disabilities, or pain scores between the groups. Both treatment arms showed significant improvements in disability, pain, and recovery scores. No significant differences were observed for subsidence, segmental motion, or fusion. For the primary outcome (i.e., RMDQ scores), the non-inferiority of Si₃N₄ compared to PEEK could not be established using the original protocol criteria. However, the comparison was undermined by larger than anticipated patient fallout coupled with higher than expected RMDQ score standard deviations. A post hoc analysis coupled with a more extensive review of the literature was conducted which resulted in the selection of a revised clinically justified non-inferiority margin; and using this method, the non-inferiority of Si₃N₄ was affirmed.

Conclusions

This study demonstrated that the use of either PEEK or Si₃N₄ cages is safe and effective for patients undergoing lumbar spine fusion for chronic degenerative disc disease.

Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptomatic State After Arthroscopic Rotator Cuff Repair

BACKGROUND

Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) are emerging criteria for patient-based treatment assessments. However, few studies have investigated these measures after rotator cuff repair.

PURPOSE

(1) To determine MCID, SCB, and PASS values for pain visual analog scale (pVAS), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, and University of California, Los Angeles (UCLA) score after arthroscopic rotator cuff repair. (2) To determine factors for achieving the MCID, SCB, and PASS.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

We analyzed prospectively collected data from a rotator cuff surgery registry between March 2018 and February 2019. Eighty-two patients were included, and anchor questions for deriving MCID, SCB, and PASS values were applied at 1-year follow-up after the surgery. The MCID and SCB for the pVAS, ASES, SANE, and UCLA scores were then derived via 2 methods: a sensitivity- and specificity-based approach, which was used alone to derive PASS values, and a between-patients approach. Additionally, univariable and multivariable logistic regression analyses were performed to determine factors for achieving the MCID, SCB, and PASS.

RESULTS

All 4 scores showed acceptable areas under the curve. MCID, SCB, and PASS values for the pVAS were 1.5, 2.5, and 1.7; for ASES scores, 21.0, 26.0, and 78.0; for SANE, 13.0, 20.0, and 71.0; and for UCLA scores, 6.0, 8.0, and 23.0, respectively. Poor preoperative scores demonstrated significantly higher odds ratios (ORs) for achieving the MCID and SCB and lower ORs for achieving the PASS. Retear, large to massive tear, and older age showed lower ORs for achieving the MCID or SCB. For PASS items, male sex and biceps tenodesis had higher ORs, and older age had lower ORs. MCID, SCB, and PASS values per the sensitivity- and specificity-based approach were applied in factor analyses.

CONCLUSION

Reliable MCID, SCB, and PASS values were obtained from patient evaluations 1 year after arthroscopic rotator cuff surgery. Poor preoperative score (MCID and SCB), male sex, and biceps tenodesis showed higher ORs, whereas poor preoperative score (PASS), retear, large to massive tear, and older age demonstrated lower ORs.

Perceived Stress and Associated Factors in Russian Medical and Dental Students: A Cross-Sectional Study in North-West Russia

The aim was to assess perceived stress (PS) and factors associated with PS in Russian medical and dental students. A total of 406 medical and 283 dental students aged 18–25 years that attended the Northern State Medical University in Arkhangelsk, North-West Russia participated in this cross-sectional study. A structured, self-administered questionnaire was used to collect information on socio-demographic and socioeconomic factors, oral health (OH) behavior, and self-reported OH. All students were clinically examined to assess dental caries, oral hygiene, and gingiva. PS was measured by the Perceived Stress Scale 10 (PSS-10). Of the students, 26.0%, 69.1%, and 4.9% reported low, moderate, and high PS, respectively. Female sex (b = 2.28, 95% confidence interval (CI): 1.38–3.18), dental faculty (b = 1.74, 95% CI: 0.94–2.54), low subjective socioeconomic status (SES) (b = 1.71, 95% CI: 0.91–2.51), and irregular dental visits (b = 1.65, 95% CI: 0.72–2.58) were associated with higher PSS-10 score. These factors were assumed to be clinical meaningful, given that minimal clinically important difference of PSS-10 fell between 2.19 and 2.66 points. The majority of the medical and dental students reported moderate PS. Based on statistical significance and clinical meaningfulness, socio-demographic factors (sex, faculty), subjective SES, and OH behavior (regularity of dental visits) were associated with PS.

Effects of preoperative obesity and psychiatric comorbidities on minimum clinically important differences for lumbar fusion in grade 1 degenerative spondylolisthesis: analysis from the prospective Quality Outcomes Database registry

OBJECTIVE

Medical comorbidities, particularly preoperatively diagnosed anxiety, depression, and obesity, may influence how patients perceive and measure clinical benefit after a surgical intervention. The current study was performed to define and compare the minimum clinically important difference (MCID) thresholds in patients with and without preoperative diagnoses of anxiety or depression and obesity who underwent spinal fusion for grade 1 degenerative spondylolisthesis.

METHODS

The Quality Outcomes Database (QOD) was queried for patients who underwent lumbar fusion for grade 1 degenerative spondylolisthesis during the period from January 2014 to August 2017. Collected patient-reported outcomes (PROs) included the Oswestry Disability Index (ODI), health status (EQ-5D), and numeric rating scale (NRS) scores for back pain (NRS-BP) and leg pain (NRS-LP). Both anchor-based and distribution-based methods for MCID calculation were employed.

RESULTS

Of 462 patients included in the prospective registry who underwent a decompression and fusion procedure, 356 patients (77.1%) had complete baseline and 12-month PRO data and were included in the study. The MCID values for ODI scores did not significantly differ in patients with and those without a preoperative diagnosis of obesity (20.58 and 20.69, respectively). In addition, the MCID values for ODI scores did not differ in patients with and without a preoperative diagnosis of anxiety or depression (24.72 and 22.56, respectively). Similarly, the threshold MCID values for NRS-BP, NRS-LP, and EQ-5D scores were not statistically different between all groups. Based on both anchor-based and distribution-based methods for determination of MCID thresholds, there were no statistically significant differences between all cohorts.

CONCLUSIONS

MCID thresholds were similar for ODI, EQ-5D, NRS-BP, and NRS-LP in patients with and without preoperative diagnoses of anxiety or depression and obesity undergoing spinal fusion for grade 1 degenerative spondylolisthesis. Preoperative clinical and shared decision-making may be improved by understanding that preoperative medical comorbidities may not affect the way patients experience and assess important clinical changes postoperatively.

Validation of the Musculoskeletal Health Questionnaire (MSK-HQ) in primary care patients with musculoskeletal pain

OBJECTIVE

To evaluate the responsiveness, and concurrent validity of the Musculoskeletal Health Questionnaire (MSK-HQ) in UK primary care patients with common musculoskeletal (MSK) pain presentations.

METHODS

A secondary analysis of a primary care pilot randomised trial (STarT MSK) was performed. In 524 people consulting with back, neck, shoulder, knee, or multi-site pain, the following were recorded at 0/6 months: MSK-HQ, EQ-5D-5L, Roland-Morris Disability Questionnaire (RMDQ; back pain), Neck Disability Index (NDI), Shoulder Pain and Disability Index (SPADI), Knee Injury and Outcome Score (KOOS), Short-Form-12 (SF-12; multisite pain). At 6-months, patients self-rated their global change in MSK condition, from -5 ("very much worse") to +5 ("completely recovered"). Receiver operating characteristic curves evaluated abilities of 6-month changes in each patient reported outcome measure (PROM) to discriminate between patients improving/not improving on global change scores, with Minimal Clinically Important Differences (MCID) calculated.

RESULTS

The MSK-HQ had a good ability to discriminate between MSK pain patients reporting global improvement vs. no improvement (area under the curve [AUC] 0.81; 95% CI 0.78, 0.85). Its discriminative ability was higher than the EQ-5D-5L (AUC 0.68; 95% CI 0.62, 0.73) and similar to site-specific PROMs. The MCID for the 6-month change in MSK-HQ was 5.5. The MSK-HQ had strong correlations with all PROMs, except SF-12 scores.

CONCLUSION

In primary care patients with common MSK pain presentations, the MSK-HQ was as good as existing pain-site specific PROMs at identifying people reporting global improvements in their MSK condition, and was better than the EQ-5D-5L.

Minimum clinically important difference of major patient-reported outcome measures in patients undergoing decompression surgery for lumbar spinal stenosis

OBJECTIVE

A minimum clinically important difference (MCID) has been increasingly well known in the current era of patient-centered care because it reflects a smallest change that is meaningful for patients following a clinical intervention. Previous studies suggested MCID values are disease and/or procedure dependent. No MCID values have been reported on the lumbar spinal stenosis (LSS) following decompression surgery despite LSS is the most common spinal disease and the main treatment is decompression surgery. Therefore, this study aimed to determine the MCID values as major outcome measures including the Numeric Rating Scale (NRS) of back pain, leg pain and numbness, Roland-Morris Disability Questionnaire (RMDQ), and Physical Component Summary (PCS) and Mental Component Summary (MCS) of Short Form 8 (SF-8) for patients with LSS undergoing decompression surgery.

PATIENTS AND METHODS

This is a retrospective cohort study using prospectively collected data from consecutive patients who underwent lumbar decompression without fusion for LSS at a single institution between May 2014 and March 2016. Inclusion criteria were 1) minimum 1-year follow-up 2) a complete set of preoperative and final follow-up questionnaires available, including the NRS, RMDQ, and SF-8. Revision surgery or non-degenerative etiology such as infection or tumor was excluded. MCIDs of each outcome measure were determined using two major approaches, distribution- and anchor-based methods. The distribution-based method uses the distributional characteristics of the sample. This method expresses the observed degree of variation to obtain a standardized metric such as the standard deviation or standard error of measurement. The anchor-based method uses an external criterion known as anchor to determine the factors that should be considered by patients for an important improvement. Anchor-based methods assess how much changes in the measurement instrument correspond with a minimal important change defined on the anchor. We used symptom severity, physical function, and satisfaction scores from Zurich Claudication Questionnaire as anchors for NRS and RMDQ, PCS, and MCS, respectively.

RESULTS

A total of 126 patients were included. From the anchor-based method, MCIDs were determined to be 2 points for back pain, 4 points for leg pain and numbness, 5 points for RMDQ, 5 points for PCS, and 2 points for MCS. From the distribution-based method, MCIDs were determined to be 2 points for back pain, leg pain and numbness, 3-4 points for RMDQ, 6 points for PCS, and 5 points for MCS.

CONCLUSION

We first identified the MCIDs of the NRS, RMDQ, and SF-8 specific to patients undergoing decompression surgery for LSS.

A digital decision support system (selfBACK) for improved self-management of low back pain: a pilot study with 6-week follow-up

Background

Very few of the publicly available apps directed towards self-management of low back pain (LBP) have been rigorously tested and their theoretical underpinnings seldom described. The selfBACK app was developed in collaboration with end-users and clinicians and its content is supported by best evidence on self-management of LBP. The objectives of this pilot study were to investigate the basis for recruitment and screening procedures for the subsequent randomized controlled trial (RCT), to test the inclusion process in relation to questionnaires and app installation, and finally to investigate the change in primary outcome over time.

Methods

This single-armed pilot study enrolled 51 participants who had sought help for LBP of any duration from primary care (physiotherapy, chiropractic, or general practice) within the past 8 weeks. Participants were screened for eligibility using the PROMIS-Physical-Function-4a questionnaire. Participants were asked to use the selfBACK app for 6 weeks. The app provided weekly tailored self-management plans targeting physical activity, strength and flexibility exercises, and education. The construction of the self-management plans was achieved using case-based reasoning (CBR) methodology to capture and reuse information from previous successful cases. Participants completed the primary outcome pain-related disability (Roland-Morris Disability Questionnaire [RMDQ]) at baseline and 6-week follow-up along with a range of secondary outcomes. Metrics of app use were collected throughout the intervention period.

Results

Follow-up data at 6 weeks was obtained for 43 participants. The recruitment procedures were feasible, and the number needed to screen was acceptable (i.e., 1.6:1). The screening questionnaire was altered during the pilot study. The inclusion process, answering questionnaires and app installation, were feasible. The primary outcome (RMDQ) improved from 8.6 (SD 5.1) at baseline to 5.9 (SD 4.0) at 6-week follow-up (change score 1.8, 95% CI 0.7 to 2.9). Participants spent on average 134 min (range 0–889 min) using the app during the 6-week period.

Conclusion

The recruitment, screening, and inclusion procedures were feasible for the subsequent RCT with a small adjustment. The improvement on the RMDQ from baseline to follow-up was small. Time pattern of app usage varied considerably between the participants.

Trial registration

NCT03697759. Registered on August 10, 2018. https://clinicaltrials.gov/ct2/show/NCT03697759

Clinically significant changes in pain along the Pain Intensity Numerical Rating Scale in patients with chronic low back pain

Low back pain (LBP) is the most common cause of chronic pain. Numerous clinical scales are available for evaluating pain, but their objective criteria in the management of LBP patients remain unclear. This study aimed to determine an objective cutoff value for a change in the Pain Intensity Numerical Rating Scale (ΔPI-NRS) three months after LBP treatment. Its utility was compared with changes in six commonly used clinical scales in LBP patients: Pain Disability Assessment Scale (PDAS), Pain Self-Efficacy Questionnaire (PSEC), Pain Catastrophizing Scale (PCS), Athens Insomnia Scale (AIS), EuroQoL 5 Dimension (EQ5D), and Locomo 25. We included 161 LBP patients treated in two representative pain management centers. Patients were partitioned into two groups based on patient’s global impression of change (PGIC) three months after treatment: satisfied (PGIC = 1, 2) and unsatisfied (3–7). Multivariate logistic regression analysis was performed to explore relevant scales in distinguishing the two groups. We found ΔPI-NRS to be most closely associated with PGIC status regardless of pre-treatment pain intensity, followed by ΔEQ5D, ΔPDAS, ΔPSEC, and ΔPCS. The ΔPI-NRS cutoff value for distinguishing the PGIC status was determined by ROC analysis to be 1.3–1.8 depending on pre-treatment PI-NRS, which was rounded up to ΔPI-NRS = 2 for general use. Spearman’s correlation coefficient revealed close relationships between ΔPI-NRS and the six other clinical scales. Therefore, we determined cutoff values of these scales in distinguishing the status of ΔPI-NRS≥2 vs. ΔPI-NRS<2 to be as follows: ΔPDAS, 6.71; ΔPSEC, 6.48; ΔPCS, 6.48; ΔAIS, 1.91; ΔEQ5D, 0.08; and ΔLocomo 25, 9.31. These can be used as definitive indicator of therapeutic outcome in the management of chronic LBP patients.

A 4-week community aquatic physiotherapy program with Ai Chi or Bad Ragaz Ring Method improves disability and trunk muscle endurance in adults with chronic low back pain: A pilot study

OBJECTIVE

To investigate the efficacy of a 4-week community aquatic physiotherapy program with Ai Chi or the Bad Ragaz Ring Method (BRRM) on pain and disability in adults with chronic low back pain (CLBP).

METHODS

Adults with CLBP (n= 44; mean ± SD age, 52.6 ± 5.5 y; 37 women) were assigned to either an Ai Chi (n= 23) or BRRM (n= 21) program (4 weeks, twice weekly).

RESULTS

Both the Ai Chi (-1.4; 95% CI -2.6 to -0.2; p= .025) and BRRM (-2.0, 95% CI -3.1 to -0.8; p= 0.003) groups demonstrated significant pre- to post-treatment decreases in Roland-Morris Disability Questionnaire scores and improvements in prone bridge duration (Ai Chi: 11.7 s; 95% CI 1.6 to 21.8; p= 0.025; BRRM: 19.0 s; 95% CI 6.1 to 31.8; p= 0.006). The Ai Chi group revealed a significant improvement in single-leg stand test duration (2.9 s; 95% CI 0.1 to 5.7; p= 0.045) and the BRRM group reported significant decrease in pain intensity (-11.6; 95% CI -19.1 to -4.2; p= 0.004).

CONCLUSIONS

A 4-week aquatic physiotherapy program with Ai Chi or BRRM resulted in significant pre- to post-treatment improvements in disability and global core muscle endurance. Ai Chi appeared to have an additional benefit of improving single-leg standing balance and BRRM an additional benefit of reducing pain.

Trunk Muscle Activation Patterns Differ Between Those With Low and High Back Extensor Strength During a Controlled Dynamic Task

It is proposed that reduced function in one of the spinal systems (active, passive, and neural) outlined by Panjabi could increase the risk of experiencing a low back injury (LBI). Also proposed is that reduced function in any one system can be compensated for by adjusting the time-varying recruitment of trunk muscles. This study addressed whether those with reduced active system function (WEAK), measured as back extensor strength, would have different trunk muscle activation patterns than those with higher function (STRONG), and secondly whether this relationship would be modified following recovery from a LBI. Sixty men participated, 30 recently recovered from LBI (rLBI, 4–12 weeks post injury) and 30 who had not had a LBI in the last year (ASYM). ASYM and rLBI participants were separated into STRONG and WEAK sub-groups if their isometric back extensor strength was above or below their group median, respectively. Trunk electromyograms from 24 muscle sites were recorded during a highly controlled horizontal transfer task. Principal component analysis captured key muscle activation patterns (amplitude and temporal); then analysis of variance models tested for strength or group*strength effects on these patterns consistent with the two main objectives. Significant strength, or group by strength effects were found for 3/4 electromyographic comparisons. In general, the WEAK group required higher activation amplitudes of abdominal and back extensor muscles, and greater temporal responsiveness of back extensor muscles only to the changing external moments than those who were STRONG. Group by strength interactions found that participants in the rLBI group had greater differences between WEAK and STRONG participants for overall muscle activation amplitudes in both abdominal and back extensor muscles. This increase in muscle activation was interpreted as compensation for lower maximum force properties whereas the increased temporal responsiveness captured a greater need to modify the agonist back extensors muscle activation patterns only in response to changes in the dynamic moments. Interactions captured that the recent experience of pain (rLBI) modified the magnitude of adjustment in muscle activation patterns potentially adapting to an increased risk of instability (painful flare) events associated with a deficit (lower strength) of the active system.

Test-Retest Reliability for Physical Function Measures in Patients with Chronic Kidney Disease

BACKGROUND

It is important to determine relative and absolute reliability values in outcome measures that are used in clinical practice so as to discriminate between true changes following exercise interventions for patients with chronic kidney disease (CKD).

OBJECTIVE

The study aimed to assess test-retest reliability of the incremental shuttle walk test (ISWT), sit-to-stand transfers in 60 seconds (STS-60), timed up and go (TUAG), Duke's activity status index (DASI) and hospital anxiety and depression scale (HAD) in patients with CKD.

STUDY DESIGN

This study was a pragmatic non-randomised controlled trial.

METHODS

Forty people attended two study visits within a 16-day window involving the ISWT, STS-60, TUAG, DASI and HAD tests. Relative reliability was assessed using intraclass correlation coefficient (ICC) and absolute reliability using the standard error of measurement (SEM) and minimal detectable change (MDC).

RESULTS

Good test-retest reliability was found for the entire sample size across all outcome measures, with TUAG having the highest (ICC = 0.96) and HAD the lowest (ICC = 0.71). The MDC scores at 90% confidence interval (CI) were: 79.6 m for the ISWT, 2.9 seconds for the TUAG, 7.0 repetitions for the STS-60, 8.4 for the DASI, 3.8 for the anxiety HAD subscale and 4.4 for the depression HAD subscale.

CONCLUSIONS

This study demonstrated good test-retest reliability for all outcome measures across the CKD trajectory but caution needs to be taken when interpreting the findings for each CKD sub-group separately. The MDC scores at 90% CI can support therapists in determining a true improvement in CKD patients' physical or mental performance.

Clinical Interpretation of the Neck Functional Status Computerized Adaptive Test

BACKGROUND

Clinical interpretation of patient-reported outcome measures is an essential step in patient-centered care. Interpretation of scores derived from the Neck Functional Status Computerized Adaptive Test (NFS-CAT) has not been studied.

OBJECTIVES

To (1) assess the reliability of point estimates and improvement scores, (2) determine thresholds of minimal clinically important improvement (MCII), and (3) develop a functional staging model to facilitate clinical interpretation of NFS-CAT scores.

METHODS

A secondary retrospective cohort analysis was performed using data from patients aged 14 to 89 years who started an episode of care for neck impairments during 2016-2017 and completed the NFS-CAT at admission. The reliability of point estimates and of improvement scores was derived from the NFS-CAT standard error of measurement. The MCII was estimated by combining distribution- and anchor-based approaches. A functional staging model was developed to describe clinical meaningfulness of the quantitative scores provided by the NFS-CAT.

RESULTS

Of 250 741 patients who completed the NFS-CAT at admission (mean ± SD age, 54 ± 16 years; 65% female), 169±039 (67%) also completed the NFS-CAT at discharge. The standard error of measurement was stable across the measurement continuum, ranging from 3.7 to 3.9 NFS-CAT points. Minimal detectable improvement was 6.8 points at the 90% confidence level. The estimate of the MCII was 8.1 points, with more change points needed to achieve the MCII for patients with lower baseline scores. Large rates of functional staging change during treatment were observed, demonstrating responsiveness of the functional staging model.

CONCLUSION

This study demonstrated how the NFS-CAT can be interpreted to better assist clinicians and patients with neck impairments during outpatient rehabilitation.

LEVEL OF EVIDENCE

Therapy, level 2b. J Orthop Sports Phys Ther 2019;49(12):875-886. Epub 10 Jul 2019. doi:10.2519/jospt.2019.8862.

King's Brief Interstitial Lung Disease questionnaire: responsiveness and minimum clinically important difference

Health status is increasingly used in clinical practice to quantify symptom burden and as a clinical trial end-point in patients with interstitial lung disease (ILD). The King's Brief Interstitial Lung Disease (KBILD) questionnaire is a brief, validated 15-item, disease-specific, health-related quality of life questionnaire that is increasingly used in clinical trials, but little data exist regarding the minimum clinically important difference (MCID). Using pulmonary rehabilitation as a model, we aimed to determine the responsiveness of KBILD and provide estimates of the MCID.KBILD scores, Chronic Respiratory Questionnaire (CRQ) scores, Medical Research Council (MRC) Dyspnoea score and incremental shuttle walk test (ISWT) distance were measured in 209 patients with ILD (105 with idiopathic pulmonary fibrosis (IPF)) before and after an outpatient pulmonary rehabilitation programme. Changes with intervention and Cohen's effect size were calculated. Anchor-based (linear regression and receiver operating characteristic plots) or distribution-based approaches (0.5 sd and standard error of measurement) were used to estimate the MCID of KBILD domain and total scores.KBILD, CRQ, MRC Dyspnoea and ISWT improved with intervention, and the effect sizes of KBILD domain and total scores ranged from 0.28 to 0.38. Using anchor-based estimates, the MCID estimates for KBILD-Psychological, KBILD-Breathlessness and activities, and KBILD-Total were 5.4, 4.4 and 3.9 points, respectively. Using distribution-based methods, the MCID estimate for KBILD-Chest symptoms was 9.8 points. The MCID estimates for KBILD in IPF patients were similar.In patients with ILD and IPF, KBILD is responsive to intervention with an estimated MCID of 3.9 points for the total score.

The responsiveness and interpretability of psychosocial patient-reported outcome measures in chronic musculoskeletal pain rehabilitation

BACKGROUND

For several widely used patient-reported outcome measures (PROMs) in chronic musculoskeletal pain (CMSP) rehabilitation, it is still not known whether they are responsive to change, and what the smallest detectable change (SDC) and minimal clinically important change (MCIC) are. Knowledge of these values can be used to accurately interpret change scores in research and clinical practice.

METHODS

In this retrospective cohort study, the responsiveness, the SDC and the MCIC of the mental components of the Research and Development 36-Item Health Survey (RAND-36), the Pain Catastrophizing Scale (PCS) and the Tampa Scale of Kinesiophobia (TSK) were investigated in CMSP patients. Responsiveness, the SDC and MCIC were determined by using both anchor and distribution-based methods.

RESULTS

For all outcome measures, there was a progression from smallest to largest mean change scores between participants who did not perceive change and those who reported change after treatment. However, correlations of the Global Perceived Effect (GPE) with the change scores on the outcome measures were low. For all outcome measures, the SDC was larger than the MCIC.

CONCLUSIONS

For this population, the questionnaires were shown not to be responsive. Furthermore, the questionnaires appeared not to be able to distinguish clinically important change from measurement error in individual patients. The finding of large measurement errors of PROMs is in line with previous research in pain rehabilitation. Using generic PROMs only, to examine changes in psychosocial status due to a pain rehabilitation programme, is therefore questionable.

SIGNIFICANCE

This study shows that widely used generic psychosocial PROMs might not be responsive and not able to distinguish clinically important change from measurement error in individual chronic musculoskeletal pain patients. It therefore seems reasonable to reconsider the (compulsory) use of these PROMs for assessing the quality of pain rehabilitation programmes, and necessary to consider other, more objective, outcome measures for this purpose in this population.

Interpreting Outcomes 3-Clinical Meaningfulness: Linking Evidence to Practice

To judge whether one treatment is more effective than another, we need to know how big the difference is. One way of judging the size of the difference reported in a trial is to ask whether it is "clinically meaningful" (or clinically worthwhile): "The smallest change that is important to patients." A treatment is often said to be "effective" and recommended for practice when the between-group difference in a study is larger than the clinically meaningful effect. But this simple idea hides some complexity. This Evidence in Practice article aims to explain the definitions, interpretations, and implications of minimally important change (MIC), minimal clinically important change (MCIC), and minimal clinically important difference (MCID). J Orthop Sports Phys Ther 2019;49(9):677-678. doi:10.2519/jospt.2019.0705.

Baseline health status and setting impacted minimal clinically important differences in COPD: an exploratory study

OBJECTIVES

Minimal clinically important differences (MCIDs) are used as fixed numbers in the interpretation of clinical trials. Little is known about its dynamics. This study aims to explore the impact of baseline score, study setting, and patient characteristics on health status MCIDs in chronic obstructive pulmonary disease (COPD).

STUDY DESIGN AND SETTING

Baseline and follow-up data on the COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ), and St. George's Respiratory Questionnaire (SGRQ) were retrospectively analyzed from pulmonary rehabilitation (PR) and routine clinical practice (RCP). Anchor- and distribution-based MCID estimates were calculated and tested between settings, gender, age, Global initiative for Obstructive Lung Disease (GOLD) classification, comorbidities, and baseline health status.

RESULTS

In total, 658 patients were included with 2,299 change score measurements. MCID estimates for improvement and deterioration ranged for all subgroups 0.50-6.30 (CAT), 0.10-0.84 (CCQ), and 0.33-12.86 (SGRQ). Larger MCID estimates for improvement and smaller ones for deterioration were noted in patients with worse baseline health status, females, elderly, GOLD I/II patients, and patients with less comorbidities. Estimates from PR were larger.

CONCLUSION

Baseline health status and setting affected MCID estimates of COPD health status questionnaires. Patterns were observed for gender, age, spirometry classification, and comorbidity levels. These outcomes would advocate the need for tailored MCIDs.