Patients' and therapists' perception of change following physiotherapy in an orthopedic hospital's outpatient clinic

Exercise- and education-based prehabilitation before total knee arthroplasty: a pilot study

OBJECTIVE

To determine the feasibility and estimates of effects of a supervised exercise- and education-based prehabilitation programme aiming to improve knee functioning compared with usual care in patients awaiting total knee arthroplasty.

DESIGN

A randomized controlled pilot study.

SUBJECTS

Patients receiving primary, unilateral total knee arthroplasty.

METHODS

Patients randomized to the intervention group participated in a personalized 4-8-week prehabilitation programme before surgery. Feasibility of the intervention and self-reported knee functioning, pain, physical performance and hospital stay were assessed at baseline, immediately preoperatively, 6 and 12 weeks after surgery.

RESULTS

Twenty patients (mean age 72.7±5.95 years) were enrolled in this study. The personalized prehabilitation programme was found to be feasible and safe, with an exercise adherence of 90%. Significant medium interaction effects between groups and over time favouring prehabilitation were reported for the sport subscale of the Knee Osteoarthritis Outcome Score (F(3/54) = 2.895, p = 0.043, η² = 0.139) and Tegner Activity Scale (F(2.2/39.1) = 3.20, p = 0.048, η² = 0.151).

CONCLUSION

The absence of adverse events and high adherence to the programme, coupled with beneficial changes shown in the intervention group, support the conduct of a full-scale trial investigating the effectiveness of prehabilitation.

Psychological, Pain, and Disability Factors Influencing the Perception of Improvement/Recovery from Physiotherapy in Patients with Chronic Musculoskeletal Pain: A Cross-Sectional Study

OBJECTIVES

The aim of this study was to identify the possible relationships between psychological, pain, and disability variables with respect to the perception of change/recovery from physiotherapy in patients with chronic musculoskeletal pain (CMP).

METHODS

A cross-sectional observational study was performed with 150 patients. All patients completed a series of self-administered questionnaires and a series of self-reports to quantify the perception of change with respect to the physiotherapy they underwent, the level of disability and pain intensity, the level of fear of movement, the level of catastrophism, the degree of self-efficacy, the level of therapeutic alliance and their adherence to the physiotherapy.

RESULTS

The strongest correlations were between the subjective perception of change and the number of sessions, treatment beliefs, self-efficacy, pain intensity, collaboration, and bonding. The linear regression model showed that the number of sessions, treatment beliefs, self-efficacy, compliance, pain intensity, and bonding were predictors of subjective perception of improvement, with 50% of the variance.

CONCLUSIONS

Treatment beliefs, therapeutic alliance, degree of self-efficacy, and pain intensity have been shown to be predictors of a subjective perception of improvement in patients with CMP. In turn, multimodal treatments had the greatest positive impact on the subjective perception of improvement.

Oral enzyme combination with bromelain, trypsin and the flavonoid rutoside reduces systemic inflammation and pain when used pre- and post-operatively in elective total hip replacement: a randomized exploratory placebo-controlled trial

Background

Early mobilization after total hip replacement (THR) is key for fast recovery but is often limited by pain. Oral enzyme combinations (OECs) have demonstrated anti-inflammatory and pain-relieving effects.

Objectives and design

This prospective, randomized, double-blind, placebo-controlled exploratory trial evaluated the effects of pre- and post-operative use of OEC (90 mg bromelain, 48 mg trypsin, 100 mg rutoside) following elective THR, on post-operative recovery.

Methods

Candidates for primary elective cementless THR owing to osteoarthritis were eligible for participation [age ⩾50 years, body mass index 25-35 kg/m2, C-reactive protein (CRP) ⩽6 mg/L]. Following randomization to OEC or placebo, intervention started pre-operatively and continued onwards until day 42. Main outcomes included post-operative CRP levels (days 1-7), self-reported hip pain at rest (by 0-10 cm visual analogue scale on post-operative days 1-42), post-operative analgesic use [by cumulative analgesic consumption score (CACS) days 7-42], tolerability and adverse events.

Results

Patients (N = 34) were recruited from a tertiary orthopaedic hospital in the Czech Republic, of whom 33 completed the study (OEC/placebo: n = 15/18). Baseline characteristics across the groups were comparable. Compared with placebo, the OEC group had numerically lower CRP levels on post-operative days 1-7, including peak level [mean (standard deviation) OEC versus placebo: 81.4 (28.3) versus 106.7 (63.3) mg/L], which translated into a significant 32% lower CRP area under the curve (p = 0.034). The OEC group reported significantly less pain during post-operative days 1-7 versus placebo (analysis of variance treatment × visit [F(4) = 3.989]; p = 0.005). Analgesic use was numerically reduced as assessed through an accumulated CACS. No deleterious effects on haemorheological parameters were observed in either group.

Conclusions

Pre- and post-operative use of OEC significantly reduced CRP levels and patient self-reported pain. OEC may be an efficacious and safe treatment option to facilitate post-operative recovery following THR.

Trial registration

EudraCT number 2016-003078-41.

Earth-vertical motion perception assessment using an elevator: a feasibility study

A feasible, inexpensive, rapid, and easy-to-use method to measure vestibular vertical movement perception is needed to assess the sacculus-mediated low-frequency otolith function of dizzy patients. To evaluate the feasibility of reaction time assessment in response to vertical motion induced by an elevator in healthy young individuals. We recorded linear acceleration/deceleration reaction times (LA-RT/LD-RT) of 20 healthy (13 female) subjects (mean age: 22 years ± 1 SD) as a measure of vertical vestibular motion perception. LA-RT/LD-RT were defined as the time elapsed from the start of elevator acceleration or deceleration to the time at which subjects in a sitting position indicated perceiving a change in velocity by pushing a button with their thumb. The light reaction time was measured as a reference. All 20 subjects tolerated the assessment with repeated elevator rides and reported no adverse events. Over all experiments, one upward and four downward rides had to be excluded for technical reasons (2.5%). The fraction of premature button presses varied among the four conditions, possibly related to elevator vibration (upward rides: LA-RT-up 66%, LD-RT-up 0%; downward rides: LA-RT-down 12%, LD-RT-down 4%). Thus LD-RT-up yielded the most robust results. The reaction time to earth-vertical deceleration elicited by an elevator provides a consistent indicator of linear vestibular motion perception in healthy humans. The testing procedure is inexpensive and easy to use. Deceleration on upward rides yielded the most robust measurements.

Global perceived improvement and health-related quality of life after physical therapy in Lebanese patients with chronic non-specific low back pain

BACKGROUND

The effectiveness of physical therapy (PT) in patients with chronic non-specific low back pain (CNSLBP) is mainly evaluated through pain, disability, and health-related quality of life (HRQOL). However, recent studies have recommended the consideration of improvement from patients' perspectives.

OBJECTIVE

This study aimed to investigate the relationship between the global perception of improvement in Lebanese patients with CNSLBP who have undergone PT, the HRQOL levels, as well as pain intensity.

METHODS

132 patients with CNSLBP who have undergone PT completed a questionnaire consisting of sociodemographic and CNSLBP characteristics questions, pain intensity numeric scale (NRS), 12-Item Short-Form Health Survey (SF-12), and the Global Perceived Effect scale (GPE). Binary logistic regressions and Pearson correlation coefficient were used for analyses.

RESULTS

Global perceived improvement of PT varies according to HRQOL levels. A significant correlation was found between pain intensity after PT, perceived improvement from PT, and HRQOL. Educational level and pain irradiation have been shown to be predictive factors of perceived improvement after PT.

CONCLUSION

Pain and HRQOL are interrelated and contributed to elucidating the global perception of improvement after PT in patients with CNSLBP. The findings suggest that patients' global perception of improvement should be considered in evaluating the benefits of physical therapy in addition to pain and HRQOL.

Assessment of clinical outcomes in patients with post-traumatic stress disorder: analysis from the UK Medical Cannabis Registry

BACKGROUND

The current paucity of clinical evidence limits the use of cannabis-based medicinal products (CBMPs) in post-traumatic stress disorder (PTSD). This study investigates health-related quality of life (HRQoL) changes and adverse events in patients prescribed CBMPs for PTSD.

METHODS

A case-series of patients from the UK Medical Cannabis Registry was analyzed. HRQoL was assessed at 1-, 3-, and 6-months using validated patient reported outcome measures (PROMs). Adverse events were analyzed according to the Common Terminology Criteria for Adverse Events version 4.0. Statistical significance was defined as p < 0.050.

RESULTS

Of 162 included patients, 88.89% (n = 144) were current/previous cannabis users. Median daily CBMP dosages were 5.00 (IQR: 0.00-70.00) mg of cannabidiol and 145.00 (IQR: 100.00-200.00) mg of Δ9-tetrahydrocannabinol. Significant improvements were observed in PTSD symptoms, sleep, and anxiety across all follow-up periods (p < 0.050). There were 220 (135.8%) adverse events reported by 33 patients (20.37%), with the majority graded mild or moderate in severity (n = 190, 117.28%). Insomnia and fatigue had the greatest incidence (n = 20, 12.35%).

CONCLUSIONS

Associated improvements in HRQoL were observed in patients who initiated CBMP therapy. Adverse events analysis suggests acceptability and safety up to 6 months. This study may inform randomized placebo-controlled trials, required to confirm causality and determine optimal dosing.

Responsiveness of the German version of the Neck Disability Index in chronic neck pain patients: a prospective cohort study with a seven-week follow-up

Background

The need for an efficient and feasible strategy to deal with neck pain has a high priority for many countries. Validated assessment tools like the Neck Disability Index (NDI) to evaluate the functional status of a neck pain patient are urgently needed to treat and to follow-up patients purposefully. A German version (NDI-G) was shown to be valid and reliable, but has so far not been tested for responsiveness. The aim of this study was to evaluate the NDI-G`s responsiveness.

Methods

This was a prospective cohort study with a seven-week follow-up. Fifty chronic neck pain patients filled out NDI-G twice. Additionally, the Patients’ Global Impression of Change score (PGIC) was assessed at follow-up. Wilcoxon and Spearman tests were used to assess direction and strength of the association between the change in NDI-G and PGIC. The receiver operating characteristics method and the area under the curve (AUC) were calculated to assess sensitivity and specificity of the NDI-G change over time.

Results

The Wilcoxon test showed statistically significant differences for NDI-G at baseline and follow-up in the total sample, the “clinically improved” and “clinically not improved” subgroups as indicated in the PGIC. Spearman test resulted in a moderate correlation between the NDI-G and the PGIC (rS = -0.53, p = 0.01) at follow-up. AUC showed an acceptable discrimination [AUC = 0.78 (95% confidence interval 0.64 – 0.91)] of the NDI-G, with a cutoff score of 1.5, between clinically improved and clinically not improved patients, based on the PGIC.

Conclusions

The NDI-G is responsive to change in chronic neck pain. Together with the results of a previous study on its validity and reliability, the NDI-G can be recommended for research and clinical settings in patients with neck pain in German speaking countries.

Trial registration

NCT02676141. February 8, 2016.

Understanding Clinical Significance in Rehabilitation: A Primer for Researchers and Clinicians

ABSTRACT

The objective of this review was to summarize the concept of clinical significance and associated methods focusing on the area of rehabilitation to provide a resource to rehabilitation researchers and clinicians. Studies were searched on electronic databases from inception until July 28, 2020, with no date or language limits. Manual searches as well as Scopus forward citation for relevant references were performed. Narrative synthesis of study results was performed. Definitions of the concepts related to clinical significance, ways of calculating, and interpreting each method were provided using rehabilitation examples. An explanation of methods to evaluate clinical significance (distribution, anchor, and opinion-based methods) and their advantages and disadvantages were also provided. Considering the limitations of statistical significance in assuring meaningfulness of results, clinical interpretation of research outcomes and the report of clinical significance in intervention trials should be a priority in rehabilitation research. When possible, the use of multiple methods (distribution, anchor, and opinion based) is recommended. Thus, clinical researchers are encouraged to present results in a manner that allow the rehabilitation professionals to easily interpret and implement those results in their clinical practice.

High-Dose Intravenous Immunoglobulin Is Effective in Painful Diabetic Polyneuropathy Resistant to Conventional Treatments. Results of a Double-Blind, Randomized, Placebo-Controlled, Multicenter Trial

OBJECTIVES

The efficacy and safety of high-dose intravenous immunoglobulin (IVIG) in treatment-resistant diabetic painful polyneuropathy (DPN) were assessed.

DESIGN

This was a randomized, double-blind, placebo-controlled, multicenter trial (EudraCT 2010-023883-42).

SETTING

This trial was conducted at eight sites in Italy with a neurology specialist level of care.

SUBJECTS

Twenty-six diabetic patients with DPN who reported baseline severity of pain >60 units (mm) on a VAS scale at enrollment and were resistant to antidepressants and antiepileptic drugs were enrolled; 23 were randomized (11 in the IVIG arm and 12 in the placebo arm). All patients completed the study and were evaluated. All patients were Caucasian, 15 were male, and 21 had a diagnosis of type II diabetes.

METHODS

IVIG (0.4 g/kg/d) or placebo was given for five consecutive days. Pain intensity (visual analog scale, Neuropathic Pain Symptom Inventory) and quality of life (36-Item Short-Form Health Survey, Clinical/Patient Global Impression of Change questionnaires) assessments were performed at visits: baseline, start of therapy (one week later), end of therapy (five days later), and follow-up (four and eight weeks later).

RESULTS

The study achieved its prespecified primary end point of ≥50% pain reduction at four weeks after IVIG, achieved in seven of 11 patients (63.6%) in the IVIG group vs zero of 12 in the placebo group (P = 0.0013). Only two adverse events were reported during the study: one patient in the treatment arm reported a mild "dermatitis psoriasiform," whereas one patient from the placebo group reported a mild "influenza."

CONCLUSIONS

Treatment with IVIG at the dose given was efficacious and safe for patients with DPN resistant to standard therapies.

Preoperative exercise in patients undergoing total knee arthroplasty: a pilot randomized controlled trial

Background

The purpose of this study was to assess the effect of preoperative physiotherapy (PT) on functional, subjective and socio-economic parameters after total knee arthroplasty (TKA).

Methods

20 patients (mean ± SD: age 67 ± 7 years) scheduled for TKA at Balgrist University Hospital between July 2016 and March 2017 were randomly assigned to a control (CG) or intervention (IG) group. 3 to 4 weeks prior to surgery the IG completed 5 to 9 sessions of PT containing proprioceptive neuromuscular facilitation (PNF) techniques, endurance training and individually indicated interventions. Measurements were executed at baseline, preoperative and 3 months after TKA. The primary outcome measure was the Stair Climbing Test (SCT), secondary outcome measures were the knee range of motion (ROM) and the level of physical activity using Lysholm Score (LS) and Tegner Activity Scale (TAS). The subjective and socio-economic parameters were the Patients’ Global Impression of Change (PGIC) scale, inpatient rehabilitation time, preoperative pain levels and metabolic equivalent (MET), postoperative intake of analgesics and overall costs.

Results

No difference between IG and CG was found for SCT (F (2/36) = 0.016, p = 0.984, η2 = 0.004). An interaction between group and time was shown for TAS (F (18/1) = 13.890) with an increase in the IG (p = 0.002, η2 = 0.536). The sub-item “pain” within the LS presented a higher pain-level in CG (F (18/1) = 4.490, p = 0.048, η2 = 0.974), while IG showed a higher preoperative MET compared to CG (p = 0.035). There were no other significant changes. The CG produced 21.4% higher overall costs, took more analgesics and showed higher preoperative pain levels than the IG.

Conclusions

Findings show that preoperative therapy improved the level of physical activity before and after TKA and resulted in a clinically relevant gain in TAS.

Trial registration

ClinicalTrials.gov Identifier; NCT03160534. Registered 19 May 2017

Patient's Subjective Impression of Cervical Range of Motion: A Mixed-methods Approach

STUDY DESIGN

Mixed-method.

OBJECTIVE

To evaluate the association between objective and subjective cervical range of motion (ROM) among patients with neck pain, and to assess the awareness of impairments.

SUMMARY OF BACKGROUND DATA

Cervical ROM is frequently used to evaluate neck pain, but it is also important to know what a patient expects from treatment, because this can profoundly affect treatment outcomes and patient satisfaction.

METHODS

We used a cervical ROM instrument, the Neck Disability Index (NDI), and a self-administered ROM questionnaire for the neck (S-ROM-Neck). Ten patients took part in semi-structured interviews. Correlations were analyzed using Spearman rank order correlations (rs). Differences between patient and assessor were evaluated by the Mann-Whitney U test. Qualitative data were analyzed by content analysis.

RESULTS

Thirty participants (mean age 43.80 years; 21 females) were included. The correlation (rs) for the S-ROM-Neck between patient and assessor was 0.679 [95% confidence interval (95% CI) 0.404-0.884; P = 0.000]. The correlation between the NDI and S-ROM-Neck was 0.178 (95% CI -0.233 to -0.533; P = 346) for the assessor and -0.116 (95% CI -0.475 to -0.219, P = 0.541) for the patient (U = 448, z = -0.030, P = 0.976). Qualitative analysis revealed that patients had general restrictions in daily life and with specific movements, but that they adjusted their behavior to avoid impairment.

CONCLUSION

There was a significant correlation between patient and therapist ratings of cervical spine mobility. Although patients experience restriction while moving and are impaired in specific activities, they adjust their lifestyle to accommodate their limitations.

LEVEL OF EVIDENCE

4.

Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain - a longitudinal observational study

Background

The influence of psychological factors on acute neck pain is sparsely studied. In a secondary analysis of prospectively collected data, this study investigated how several psychological factors develop in the first three months of acute neck pain and how these factors influence self-perceived recovery.

Methods

Patients were recruited in various chiropractic practices throughout Switzerland between 2010 and 2014. The follow-up telephone interviews were conducted for all patients by research assistants in the coordinating university hospital following a standardized procedure. The population of this study consisted of 103 patients (68 female; mean age = 38.3 ± 13.8 years) with a first episode of acute (<4 weeks) neck pain. Prior to the first treatment, the patients filled in the Bournemouth Questionnaire (BQ). One week and 1 and 3 months later, they completed the BQ again along with the Patient Global Impression of Change (PGIC). The temporal development (repeated measure ANOVA) of the BQ questions 4 (anxiety), 5 (depression), 6 (fear-avoidance) and 7 (pain locus of control) as well as the influence of these scores on the PGIC were investigated (binary logistic regression analyses, receiver operating curves (ROC)).

Results

All psychological parameters showed significant reduction within the first month. The parameter ‘anxiety’ was associated with outcome at 1 and 3 months (p = 0.013, R² = 0.40 and p = 0.039, R² = 0.63, respectively). Baseline depression (p = 0.037, R² = 0.21), but not baseline anxiety, was a predictor for poor outcome. A high reduction in anxiety within the first month was a significant predictor for favorable outcome after 1 month (p < 0.001; R² = 0.57).

Conclusions

Psychological factors emerged from this study as relevant in the early phase of acute neck pain. Particularly persistent anxiety and depression at baseline might be risk factors for a transition to chronic pain that should be addressed in the early management of neck pain patients.

Testing pilocarpine drops for dry mouth in advanced cancer using n-of-1 trials: A feasibility study

BACKGROUND

Dry mouth is a common and troublesome symptom in palliative care. Pilocarpine is a cholinergic agent that promotes salivation.

AIM

This study aimed to test the feasibility of using n-of-1 trials to test pilocarpine drops compared to placebo, for patients of palliative care units with advanced cancer, who experienced dry mouth.

DESIGN

This was an N-of-1 study, in which each participant was offered three cycles of pilocarpine drops 4% (6 mg tds) (3 days) and placebo drops (3 days) in random order.

SETTING/PARTICIPANTS

Participants were patients of specialist palliative care services with advanced cancer assessed as having a dry mouth, defined as having a score of ⩾ 3 on an 11-point self-rated xerostomia numerical rating scale, from any cause. Patients self-completed a diary using validated symptom and quality-of-life scores. The randomisation order was unmasked at the end of each person's trial by a clinician independent of the trial to allow a treatment decisions for individual patients to be made.

RESULTS

Nine patients completed at least 1 cycle; 33 cycles of data were completed in total, comprising 438 doses of pilocarpine. Four patients completed the trial: two responded and two did not. Most withdrawals related to deteriorating condition, unacceptable toxicity, non-compliance with study procedures or withdrawal of consent. Many issues contributed to slow recruitment and high withdrawal rate.

CONCLUSION

The formulation of pilocarpine drops proved unacceptable to most participants. More work is required to determine an appropriate formulation, dose and method of delivery and then a retest of pilocarpine drops for this symptom.

Effect of manual versus mechanically assisted manipulations of the thoracic spine in neck pain patients: study protocol of a randomized controlled trial

BACKGROUND

Neck pain is a common musculoskeletal condition with a point prevalence of around 15% in males and 23% in females that often presents in physiotherapy practice. Physical therapy and/or manipulation therapy is generally the first management option for patients with mechanical neck pain. Physical therapists treat mechanical neck pain with a number of interventions including joint mobilization and/or manipulation, therapeutic exercises or education. However, manipulation of the cervical spine carries some risks. Treating the thoracic spine for neck pain is an alternative approach. Emerging evidence suggests that it may be effective for treating neck pain without the risks associated with cervical spine manipulation. A new electromechanical device has recently been developed and tested for delivering multiple high velocity, low amplitude thrust manipulations to the spine. This device incorporates both auditory and visual systems that provide real time feedback on the applied treatment. The objective of this study is to compare the short- and long-term effects of manual versus mechanically assisted manipulations of the thoracic spine for neck pain patients.

METHODS/DESIGN

A 6-month, randomized controlled trial consisting of 54 patients with acute or chronic neck pain patients will be conducted. Patients with no signs of major pathology and with little or no interference with daily activities will be recruited. Three treatment sessions with 4-day intervals will be carried out. The patients will be randomly assigned to receive either manually performed manipulations or electromechanical manipulations at the thoracic spine. The primary outcome is pain intensity as measured by the Visual Analogue Pain Rating Scale. The secondary outcome measures are neck physical disability using the Neck Disability Index, quality of life measured by the European Quality of Life 5 Dimensions 5 Levels and patients' improvement using the Patient's Global Impression of Change Scale.

DISCUSSION

It is expected that both interventions will improve neck pain. This would be a significant finding, as thoracic spine manipulation for neck pain does not carry the same risk of injury as cervical spine manipulation. In addition, the results may provide useful information about therapeutic options for health care providers and patients for the problem of neck pain.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN88585962, registered January 2013.