Statistical significant change versus relevant or important change in (quasi) experimental design: some conceptual and methodological problems in estimating magnitude of intervention-related change in health services research

Comparing the EQ-5D-5L and stroke impact scale 2.0 in stroke patients: an analysis of measurement properties

BACKGROUND

Stroke has evolved to become a chronic disease and a major public health challenge. To adequately capture the full disease burden of stroke patients, the assessment of health-related quality of life (HRQoL) and thus the performance of respective measures is increasingly relevant. The aim of this analysis was to compare the measurement properties of two self-report instruments, the EQ-5D-5L and the Stroke Impact Scale 2.0.

METHODS

The data used for the analysis was derived from a quasi-experimental case management study for mildly to moderately affected incident stroke and transient ischemic attack (TIA) patients aged ≥ 18 in Germany. Data was collected patient-individually at 3, 6 and 12 months after initial stroke. The EQ-5D-5L and SIS 2.0 were compared in terms of feasibility, ceiling and floor effects, responsiveness and known-groups validity (Kruskal-Wallis H and Wilcoxon rank-sum test).

RESULTS

A response for all three follow-ups is available for n = 855 patients. The feasibility of the EQ-5D-5L is determined as good (completion rate: 96.4-96.6%, ≥ one item missing: 3.2 - 3.3%), whereas the SIS 2.0 is moderately feasible (overall completion rate: 44.9-46.1%, ≥ one item missing in domains: 4.7 - 28.7%). The SIS 2.0 shows substantial ceiling effects in comparable domains (physical function: 10.4 - 13%, others: 3.5-31.3%) which are mainly larger than ceiling effects in the EQ-5D-5L index (17.1-21.5%). In terms of responsiveness, the EQ-5D-5L shows small to moderate change while the SIS 2.0 presents with moderate to large responsiveness. The EQ-5D-5L index, mobility, usual activities and Visual Analogue Scale show known-groups validity (p < 0.05). Content-related domains of the SIS 2.0 show known-groups validity as well (p < 0.05). However, it is compromised in the emotion domain in both measures (p > 0.05).

CONCLUSIONS

The EQ-5D-5L seems to be slightly more suitable for this cohort. Nonetheless, the results of both measures indicate limited suitability for TIA patients. Large-scale studies concerning responsiveness and known-groups validity are encouraged.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register, retrospective registration on 21.09.2022.

REGISTRATION ID

DRKS00030297.

Responsiveness of Subjective and Objective Measures of Pain and Function Following Operative Interventions for Musculoskeletal Conditions: A Narrative Review

OBJECTIVE

Musculoskeletal (MSK) disorders affect ~50% of US adults and 75% of those over the age of 65, representing a sizable economic and disability burden. Outcome measures, both objective and subjective, help clinicians and investigators determine whether interventions to treat MSK conditions are effective. This narrative review qualitatively compared the responsiveness of different types of outcome measures, a key measurement characteristic that assesses an outcome measure's ability to detect change in patient status.

METHODS

We evaluated elective orthopedic interventions as a model for assessing responsiveness because the great majority of patients improves following surgery. We searched for articles reporting responsiveness (quantified as effect size [ES]) of subjective and objective outcome measures after orthopedic surgery and included 16 articles reporting 17 interventions in this review.

RESULTS

In 14 of 17 interventions, subjective function measures had an ES 10% greater than that of objective function measures. Two reported a difference in ES of <10%. The sole intervention that demonstrated higher ES of objective function used a composite measure. Sixteen interventions reported measures of subjective pain and/or mixed measures and subjective function. In nine interventions, subjective pain had a higher ES than subjective function by >10%, in three, subjective function had a higher ES than subjective pain by >10%, and in the remaining four, the difference between pain and function was <10%.

CONCLUSION

These findings reinforce the clinical observation that subjective pain generally changes more than function following elective orthopedic surgery. They also suggest that subjective function measures are more responsive than objective function measures, and composite scores may be more responsive than individual performance tests.

Validation of the Oswestry Disability Index in Adult Spinal Deformity

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To examine the validity of the Oswestry Disability Index (ODI) in patients with adult spinal deformity (ASD) treated with surgery.

BACKGROUND

The ODI is a patient-reported outcome measure of low back pain and disability. Although nearly ubiquitous in ASD research, the measure has not been validated in this patient population.

PATIENTS AND METHODS

A registry of patients with ASD was queried for baseline and 1-year PROM data, including the ODI, the Scoliosis Research Society-22r (SRS-22r), and the Patient Reported Outcomes Measurement Information System-Pain Interference (PI) and Physical Function (PF) CATs. Internal reliability was assessed with Cronbach alpha, where values ≥0.7 are considered reliable. Validity was assessed with Spearman correlation coefficients calculated for the ODI against validated Patient-Reported Outcomes Measurement Information System (PROMIS)-PI and PF, and legacy measures SRS-Pain and SRS-Activity. Responsiveness to change was measured with the adjusted effect size.

RESULTS

A total of 325 patients were enrolled, with 208 completing baseline and 1-year patient-reported outcome measures. The majority (149, 72%) were females and White (193, 93%), median Charlson Comorbidity Index 0 (interquartile range: 0-2). The majority of cases included sagittal plane deformity [mean T1PA: 24.2° (13.9)]. Cronbach alpha showed excellent internal reliability (baseline = 0.89, 1 yr = 0.90). ODI was valid, with strong correlations between PROMIS-PI, PROMIS-PF, SRS-Pain, and SRS-Activity at baseline and 1-year follow-up. All measures were responsive to change, with the ODI showing greater responsiveness than PROMIS-PI, PROMIS-PF, and SRS-Activity.

CONCLUSIONS

The ODI is a valid measure of disability as measured by pain and function in patients with ASD. It is responsive to change in a manner not different from validated PROMIS-CAT or the SRS-22r legacy measure. It is multidimensional, however, as it assesses both pain and function simultaneously. It does not measure disability related to self-image and may not account for all disease-related disability in patients with ASD.

Effect size varies based on calculation method and may affect interpretation of treatment effect: an illustration using randomised clinical trials in osteoarthritis

BACKGROUND

To illustrate how (standardised) effect sizes (ES) vary based on calculation method and to provide considerations for improved reporting.

METHODS

Data from three trials of tanezumab in subjects with osteoarthritis were analyzed. ES of tanezumab versus comparator for WOMAC Pain (outcome) was defined as least squares difference between means (mixed model for repeated measures analysis) divided by a pooled standard deviation (SD) of outcome scores. Three approaches to computing the SD were evaluated: Baseline (the pooled SD of WOMAC Pain values at baseline [pooled across treatments]); Endpoint (the pooled SD of these values at the time primary endpoints were assessed); and Median (the median pooled SD of these values based on the pooled SDs across available timepoints). Bootstrap analyses were used to compute 95% confidence intervals (CI).

RESULTS

ES (95% CI) of tanezumab 2.5 mg based on Baseline, Endpoint, and Median SDs in one study were - 0.416 (- 0.796, - 0.060), - 0.195 (- 0.371, - 0.028), and - 0.196 (- 0.373, - 0.028), respectively; negative values indicate pain improvement. This pattern of ES differences (largest with Baseline SD, smallest with Endpoint SD, Median SD similar to Endpoint SD) was consistent across all studies and doses of tanezumab.

CONCLUSION

Differences in ES affect interpretation of treatment effect. Therefore, we advocate clearly reporting individual elements of ES in addition to its overall calculation. This is particularly important when ES estimates are used to determine sample sizes for clinical trials, as larger ES will lead to smaller sample sizes and potentially underpowered studies.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02697773, NCT02709486, and NCT02528188.

A multisite feasibility randomized clinical trial of mindfulness-based resilience training for aggression, stress, and health in law enforcement officers

BACKGROUND

Law enforcement officers (LEOs) are exposed to significant stressors that can impact their mental health, increasing risk of posttraumatic stress disorder, burnout, at-risk alcohol use, depression, and suicidality. Compromised LEO health can subsequently lead to aggression and excessive use of force. Mindfulness training is a promising approach for high-stress populations and has been shown to be effective in increasing resilience and improving mental health issues common among LEOs.

METHODS

This multi-site, randomized, single-blind clinical feasibility trial was intended to establish optimal protocols and procedures for a future full-scale, multi-site trial assessing effects of mindfulness-based resilience training (MBRT) versus an attention control (stress management education [SME]) and a no-intervention control, on physiological, attentional, and psychological indices of stress and mental health. The current study was designed to enhance efficiency of recruitment, engagement and retention; optimize assessment, intervention training and outcome measures; and ensure fidelity to intervention protocols. Responsiveness to change over time was examined to identify the most responsive potential proximate and longer-term assessments of targeted outcomes.

RESULTS

We observed high feasibility of recruitment and retention, acceptability of MBRT, fidelity to assessment and intervention protocols, and responsiveness to change for a variety of putative physiological and self-report mechanism and outcome measures.

CONCLUSIONS

Results of this multi-site feasibility trial set the stage for a full-scale, multi-site trial testing the efficacy of MBRT on increasing LEO health and resilience, and on decreasing more distal outcomes of aggression and excessive use of force that would have significant downstream benefits for communities they serve.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03784846 . Registered on December 24th, 2018.

Responsiveness and minimal important change of the Family Reported Outcome Measure (FROM-16)

BACKGROUND

The FROM-16 is a generic family quality of life (QoL) instrument that measures the QoL impact of patients' disease on their family members/partners. The study aimed to assess the responsiveness of FROM-16 to change and determine Minimal Important Change (MIC).

METHODS

Responsiveness and MIC for FROM-16 were assessed prospectively with patients and their family members recruited from outpatient departments of the University Hospital Wales and University Hospital Llandough, Cardiff, United Kingdom. Patients completed the EQ-5D-3L and a global severity question (GSQ) online at baseline and at 3-month follow-up. Family members completed FROM-16 at baseline and a Global Rating of Change (GRC) in addition to FROM-16 at follow-up. Responsiveness was assessed using the distribution-based (effect size-ES, standardized response mean -SRM) and anchor-based (area under the receiver operating characteristics curve ROC-AUC) approaches and by testing hypotheses on expected correlation strength between FROM-16 change score and patient assessment tools (GSQ and EQ-5D). Cohen's criteria were used for assessing ES. The AUC ≥ 0.7 was considered a good measure of responsiveness. MIC was calculated using anchor-based (ROC analysis and adjusted predictive modelling) and distribution methods based on standard deviation (SD) and standard error of the measurement (SEM).

RESULTS

Eighty-three patients with 15 different health conditions and their relatives completed baseline and follow-up questionnaires and were included in the responsiveness analysis. The mean FROM-16 change over 3 months = 1.43 (SD = 4.98). The mean patient EQ-5D change over 3 months = -0.059 (SD = 0.14). The responsiveness analysis showed that the FROM-16 was responsive to change (ES = 0.2, SRM = 0.3; p < 0.01). The ES and SRM of FROM-16 change score ranged from small (ES = 0.2; SRM = 0.3) for the distribution-based method to large (ES = 0.8, SRM = 0.85) for anchor-based methods. The AUC value was above 0.7, indicating good responsiveness. There was a significant positive correlation between the FROM-16 change scores and the patient's disease severity change scores (p < 0.001). The MIC analysis was based on data from 100 family members of 100 patients. The MIC value of 4 was suggested for FROM-16.

CONCLUSIONS

The results of this study confirm the longitudinal validity of FROM-16 which refers to the degree to which an instrument is able to measure change in the construct to be measured. The results yield a MIC value of 4 for FROM-16. These psychometric attributes of the FROM-16 instrument are useful in both clinical research as well as clinical practice.

Psychometric evaluation of the modified quality of recovery score for the postanaesthesia care unit (QoR-PACU2)-A prospective validation study

BACKGROUND

To date, there is no instrument to adequately assess self-reported quality of recovery (QoR) in the post-anesthesia care unit (PACU). We previously developed the QoR-PACU, a 13-item questionnaire specifically applicable to the PACU. The feasibility, acceptance, and validity of the QoR-PACU were promising. However, measures of reliability were slightly lower than expected.

METHODS

We modified the QoR-PACU and evaluated its psychometric properties in a cohort of adult patients scheduled for non-cardiac surgery with general anesthesia. The modified QoR-PACU (termed QoR-PACU2) was administered before surgery and postoperatively in the PACU at the time of the decision to discharge.

RESULTS

A total of 307 patients were included in the final analysis. Postoperative QoR-PACU2 sum scores differed across categories of sex, perioperative and surgical risk, and modes of airway management. The duration of anesthesia and surgery, maximum pain intensity and analgesic requirement in the PACU, and length of PACU stay were all inversely correlated with QoR in the PACU. Cronbach's alpha was 0.70 (95%CI: 0.66-0.75). The intra-class correlation coefficient was 0.86 (95%CI: 0.70-0.94, p < 0.001) for intra-rater reliability (n = 24) and 0.94 (95%CI 0.90 to 0.97, p < 0.001) for inter-rater reliability (n = 31). Cohen's effect size was 0.68 and the standardized response mean was 0.57.

CONCLUSION

The QoR-PACU2 assesses self-reported QoR after surgery in the PACU. Measures of feasibility, validity, and reliability were consistently high. Measures of responsiveness were moderate, which might be attributable to the heterogeneity of the study population. Future studies should include aspects of ethnicity and cross-cultural applicability.

Health-related quality of life and experience measures, to assess patients' experiences of peripheral intravenous catheters: a secondary data analysis

BACKGROUND

Peripheral intravenous catheters (PIVCs) are essential for successful administration of intravenous treatments. However, insertion failure and PIVC complications are common and negatively impact patients' health-outcomes and experiences. We aimed to assess whether generic (not condition-specific) quality of life and experience measures were suitable for assessing outcomes and experiences of patients with PIVCs.

METHODS

We undertook a secondary analysis of data collected on three existing instruments within a large randomised controlled trial, conducted at two adult tertiary hospitals in Queensland, Australia. Instruments included the EuroQol Five Dimension - Five Level (EQ5D-5L), the Functional Assessment of Chronic Illness Therapy - Treatment Satisfaction - General measure (FACIT-TS-G, eight items), and the Australian Hospital Patient Experience Question Set (AHPEQS, 12 items). Responses were compared against two clinical PIVC outcomes of interest: all-cause failure and multiple insertion attempts. Classic descriptives were reported for ceiling and floor effects. Regression analyses examined validity (discrimination). Standardised response mean and effect size (ES) assessed responsiveness (EQ5D-5L, only).

RESULTS

In total, 685 participants completed the EQ5D-5L at insertion and 526 at removal. The FACIT-TS-G was completed by 264 and the AHPEQS by 262 participants. Two FACIT-TS-G items and one AHPEQS item demonstrated ceiling effect. Instruments overall demonstrated poor discrimination, however, all-cause PIVC failure was significantly associated with several individual items in the instruments (e.g., AHPEQS, 'unexpected physical and emotional harm'). EQ5D-5L demonstrated trivial (ES < 0.20) responsiveness.

CONCLUSIONS

Initial investigation of an existing health-related quality of life measure (EQ5D-5L) and two patient-reported experience measures (FACIT-TS-G; AHPEQS) suggest they are inadequate (as a summary measure) to assess outcomes and experiences for patients with PIVCs. Reliable instruments are urgently needed to inform quality improvement and benchmark standards of care.

Comparable Minimally Important Differences and Responsiveness of Brief Pain Inventory and PEG Pain Scales across 6 Trials

The 3-item pain intensity (P), interference with the enjoyment of life (E), and interference with general activity (G), or PEG, has become one of the most widely used measures of pain severity and interference. The minimally important differences (MID) and responsiveness of the PEG are essential metrics for solidifying its role in research and clinical care. The current study aims to establish the MID and responsiveness of the PEG by synthesizing data from 1,710 participants across 6 controlled trials. MIDs were estimated using absolute score changes among individuals reporting their pain was "a little better" on a retrospective global change anchor as well as distribution-based estimates using standard deviation thresholds and 1 and 2 standard errors of measurement. Responsiveness was assessed using standardized response means, area under the curve, and treatment effect sizes. MID estimates for the PEG ranged from 0.60 to 1.1 when using 0.35 SD, and 0.78 to 1.22 using 1 standard error of measurement. MID estimates using the global anchor had somewhat more variability but most estimates ranged from 1.0 to 1.75. Responsiveness effect sizes were generally large (>.80) for standardized response means and moderate (>.50) for treatment effect. Similarly, the most area under the curve values demonstrated an acceptable level of scale responsiveness (≥.70). Importantly, MID estimates and responsiveness of the PEG and BPI scales were largely comparable when aggregating data across trials. Our synthesis indicates that 1 point is a reasonable MID estimate on these 0- to 10-point pain scales, with 2 points being an upper bound. PERSPECTIVE: This article synthesizes data from 6 clinical trials to establish the minimally important difference (MID) and responsiveness of the 3-item PEG pain scale. The PEG demonstrated good responsiveness, and 1 to 2 points proved to be reasonable estimates for the lower and upper bounds of the MID.

Dry needling combined with exercise therapy: Effects on wrist flexors spasticity in post-stroke patients - A randomized controlled trial

BACKGROUND

The positive contribution of dry needling (DN) in conjunction with exercise therapy for patients with stroke and spasticity remains uncertain.

OBJECTIVE

To examine the effects of DN combined with exercise therapy on wrist flexor spasticity and motor function in patients with stroke.

METHODS

Twenty-four participants with stroke were randomly assigned to either the DN and exercise therapy group or the DN alone group. Assessments were conducted at baseline, after the 4th treatment session, and 3 weeks post-treatment.

RESULTS

A significant Group×Time interaction was observed for wrist active range of motion (ROM) (P = 0.046), favoring the DN with exercise therapy group (∼10° at baseline, ∼15° immediately after the 4th session, and 15.4° at follow-up). The improvements in spasticity, passive ROM, and H-reflex latency were sustained during follow-up. However, there were no significant between-group differences in any outcome at any measurement time point.

CONCLUSION

The combined DN and exercise therapy did not exhibit superiority over DN alone concerning spasticity severity and motor function. However, it demonstrated additional advantages, particularly in improving motor neuron excitability and wrist passive extension.

Stride Velocity 95th Centile Detects Decline in Ambulatory Function Over Shorter Intervals than the 6-Minute Walk Test or North Star Ambulatory Assessment in Duchenne Muscular Dystrophy

Background

Stride Velocity 95th Centile (SV95C) is the first wearable device-derived clinical outcome assessment (COA) to receive European Medicines Agency (EMA) qualification as a primary endpoint in ambulant patients with Duchenne muscular dystrophy (DMD) aged ≥4 years.

Objective

To compare SV95C-in its first-ever clinical trial application as a secondary endpoint-with established motor function COAs used in the trial (Four-Stair Climb [4SC] velocity, North Star Ambulatory Assessment [NSAA], and Six-Minute Walk Distance [6MWD]).

Methods

SV95C was a secondary endpoint in a subset (n = 47) of participants in the SPITFIRE/WN40227 trial of taldefgrobep alfa, which was discontinued due to lack of clinical benefit. Participants in the ≤48-week SV95C sub-study were 6-11 years old and received corticosteroids for ≥6 months pre-treatment. Pearson correlations were used to compare SV95C with the other COAs. Responsiveness and changes over time were respectively assessed via standardized response means (SRMs) based on absolute changes and mixed models for repeated measures.

Results

SV95C change at Week 24 was -0.07 m/s, with limited variability (standard deviation: 0.16, n = 27). The SRM for SV95C indicated moderate responsiveness to clinical change at the earliest timepoint (Week 12, n = 46), while those of the other COAs did not indicate moderate responsiveness until Week 36 (6MWD, n = 33) or Week 48 (4SC velocity, n = 20; NSAA total score, n = 20). Baseline correlations between SV95C and other COAs were strong (r = 0.611-0.695). Correlations between SV95C change from baseline to Week 48 and changes in other COAs were moderate to strong (r = 0.443-0.678).∥.

Conclusions

Overall, SV95C demonstrated sensitivity to ambulatory decline over short intervals, low variability, and correlation with established COAs. Although the negative trial precluded demonstration of SV95C's sensitivity to drug effect, these findings support the continued use of SV95C in DMD clinical trials.

Responsiveness of Section GG Scores in Tracking Post-Stroke Functional Recovery From Inpatient Rehabilitation Admission to 90-Day Follow-Up

OBJECTIVE

To evaluate the responsiveness and scale-to-sample targeting of Section GG of the Inpatient Rehabilitation Facility-Patient Assessment Instrument in measuring the trajectory of functional recovery in patients with stroke from inpatient rehabilitation admission to 90 days after discharge.

DESIGN

Retrospective cohort study.

SETTING

150-bed inpatient rehabilitation facility.

PARTICIPANTS

Patients with stroke (N=1087) discharged between December 2019 to April 2021.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Admission and discharge self-care and mobility scores from Section GG were analyzed for the Inpatient Only group (n= 817). Admission, discharge and 90-day post-discharge Section GG scores from telephone interviews with patients or caregivers were analyzed for the Follow-Up group (n=270). Standardized response means (SRM) determined responsiveness of the tool for each group and time interval. Score means, standard deviations, and floor/ceiling effects illustrated scale-to-sample targeting of the tool.

RESULTS

Self-care and mobility scores improved significantly from admission to discharge (P<.001) for both groups and from discharge to 90 days (P<.001) for the Follow-Up group. Large SRM existed from admission to discharge for self-care and mobility scores in both groups. ​A small-to-moderate SRM was seen from discharge to 90 days for self-care (0.46) and a moderate SRM was observed for mobility (0.68). Overall floor effects were minor at admission for self-care (9.8%) and mobility (7.2.%). Overall ceiling effects were minor at discharge for self-care (11.2%) and mobility (4.6%)​ and significant at follow-up for both self-care (45.2%) and mobility (32.2%).

CONCLUSIONS

Section GG is responsive to change and appropriately measures patients' functional ability during inpatient rehabilitation. More study is required for telephone follow-up after discharge from inpatient rehabilitation.

Comparisons of EQ-5D-Y and PedsQL in pediatric patients with mild-to-moderate chronic kidney disease in longitudinal analyses

OBJECTIVE

To characterize longitudinal changes and correlations between the measures of EQ-5D-Y and generic PedsQL and their associations with clinical changes in children and adolescents with mild-to-moderate chronic kidney disease (CKD).

METHODS

Participants were recruited from January 2017 to September 2021 in a medical center in Taiwan. Both instruments were administered in their initial visits and every 6-month subsequent visits. Spearman's Rho (ρ) was used to assess correlations between the scores of EQ-5D-Y and PedsQL measures in longitudinal changes. Cohen's effect size (ES) was used to evaluate the changes of scores/subscales over time. In addition, factors associated with longitudinal changes in the score/subscales were explored.

RESULTS

A total of 121 participants were enrolled, and 83 with ≥ 3 HRQOL measures during the 3.5 years follow-up were assessed their changes of HRQOL measures. The correlations (ρ > 0.3) appeared between the changes in the visual analog scale (VAS) of EQ-5D-Y and emotional and social subscales of PedsQL. ES was small (< 0.5) in the VAS and level-sum-score (LSS) of EQ-5D-Y scores for the clinical changes in comorbidities, while some PedsQL subscales were medium to high (0.5-0.8 or > 0.8). Hypertension, mineral bone disorder/anemia, and hyperuricemia associated with the changes in both HRQOL scores were varied by their various domains.

CONCLUSION

Both EQ-5D-Y and PedsQL of HRQOL measures were responsive to worsened childhood CKD-related comorbidities during the follow-up; however, convergent validity between them was limited in some domains. The LSS of EQ-5D-Y showed greater changes than the VAS by comorbidity status; further comparison with utility weight is needed to determine the better performance of EQ-5D-Y.

Responsiveness of specific and generic patient-reported outcome measures in patients with plantar fasciopathy

PURPOSE

To evaluate and compare responsiveness characteristics for the Foot Function Index revised short form (FFI-RS), RAND-12 Health Status Inventory (RAND-12), and Numeric Rating Scale (NRS), in patients with plantar fasciopathy receiving non-surgical treatment.

MATERIALS AND METHODS

This study was conducted on a sub-group of patients from an ongoing randomised controlled trial. One-hundred fifteen patients were included. The patient-reported outcome measures (PROMs) were applied at baseline and after 6 months. Responsiveness was calculated using standardised response mean and area under the receiver operating characteristic (ROC) curve. ROC curves were used to compute the minimal important change (MIC) for the outcome measures.

RESULTS

The region specific FFI-RS had best responsiveness and the NRS at rest had lowest responsiveness.

CONCLUSION

FFI-RS were marginally more responsive than the other PROMs. Responsiveness and MIC estimates should be regarded as indicative rather than fixed estimates.

Dual task measures in older adults with and without cognitive impairment: response to simultaneous cognitive-exercise training and minimal clinically important difference estimates

BACKGROUND

Responsiveness and minimal clinically important difference (MCID) are critical indices to understand whether observed improvement represents a meaningful improvement after intervention. Although simultaneous cognitive-exercise training (SCET; e.g., performing memory tasks while cycling) has been suggested to enhance the cognitive function of older adults, responsiveness and MCID have not been established. Hence, we aimed to estimate responsiveness and MCIDs of two dual task performance involving cognition and hand function in older adults with and without cognitive impairment and to compare the differences in responsiveness and MCIDs of the two dual task performance between older adults with and without cognitive impairment.

METHODS

A total of 106 older adults completed the Montreal Cognitive Assessment and two dual tasks before and after SCET. One dual task was a combination of Serial Sevens Test and Box and Block Test (BBT), and the other included frequency discrimination and BBT. We used effect size and standardized response mean to indicate responsiveness and used anchor- and distribution-based approaches to estimating MCID ranges. When conducting data analysis, all participants were classified into two cognitive groups, cognitively healthy (Montreal Cognitive Assessment ≥ 26) and cognitively impaired (Montreal Cognitive Assessment < 26) groups, based on the scores of the Montreal Cognitive Assessment before SCET.

RESULTS

In the cognitively healthy group, Serial Seven Test performance when tasked with BBT and BBT performance when tasked with Serial Seven Test were responsive to SCET (effect size = 0.18-0.29; standardized response mean = 0.25-0.37). MCIDs of Serial Seven Test performance when tasked with BBT ranged 2.09-2.36, and MCIDs of BBT performance when tasked with Serial Seven Test ranged 3.77-5.85. In the cognitively impaired group, only frequency discrimination performance when tasked with BBT was responsive to SCET (effect size = 0.37; standardized response mean = 0.47). MCIDs of frequency discrimination performance when tasked with BBT ranged 1.47-2.18, and MCIDs of BBT performance when tasked with frequency discrimination ranged 1.13-7.62.

CONCLUSIONS

Current findings suggest that a change in Serial Seven Test performance when tasked with BBT between 2.09 and 2.36 corrected number (correct responses - incorrect responses) should be considered a meaningful change for older adults who are cognitively healthy, and a change in frequency discrimination performance when tasked with BBT between 1.47 and 2.18 corrected number (correct responses - incorrect responses) should be considered a meaningful change for older adults who are cognitively impaired. Clinical practitioners may use these established MCIDs of dual tasks involving cognition and hand function to interpret changes following SCET for older adults with and without cognitive impairment.

TRIAL REGISTRATION

NCT04689776, 30/12/2020.

Measurement properties of the patient global assessment numerical rating scale in moderate-to-severe psoriasis

BACKGROUND

Patient global assessment (PtGA) has been recommended as one of the core domains in psoriasis clinical trials. Among multiple versions of PtGA, the single-question, 11-point PtGA numeric rating scale (NRS) remains to be validated in patients with plaque psoriasis.

OBJECTIVES

To evaluate the psychometric characteristics of an 11-point PtGA NRS for disease severity in patients with moderate-to-severe plaque psoriasis.

METHODS

Data were analysed from 759 patients with moderate-to-severe psoriasis in the Shanghai Psoriasis Effectiveness Evaluation CoHort (SPEECH), a prospective, multicentre and observational registry assessing the comparative effectiveness and safety of biologics (adalimumab, ustekinumab, secukinumab or ixekizumab), conventional systemic therapies (acitretin or methotrexate) and phototherapy.

RESULTS

The test-retest reliability of the PtGA NRS showed good agreement (intraclass correlation coefficient range 0.79-0.83). No floor or ceiling effects of PtGA NRS were observed. The PtGA NRS was significantly correlated with the Psoriasis Area and Severity Index (PASI), static Physician Global Assessment (sPGA), body surface area, Dermatology Quality of Life Index (DLQI) and Hospital Anxiety and Depression Scale. Relatively large correlations of PtGA NRS with PASI and the DLQI 'symptoms and feelings' domain (all correlations ≥ 0.4 except at baseline) supported convergent validity. The presence of psoriatic arthritis or joint symptoms had no significant association with the PtGA NRS. In multivariate regression analyses, the PtGA NRS at baseline was predicted by age, lesion extent, lesion intensity, patients' symptoms and feelings, and impact on work or school. The PtGA NRS displayed known-groups validity with the PASI, sPGA and DLQI score bands. The PtGA NRS was responsive to change in PASI and DLQI after treatment. Anchor- and distribution-based approaches supported -3 as the minimal important difference for PtGA NRS. An absolute PtGA NRS ≤ 2 during follow-up was concordant with the state of minimal disease activity based on a 90% reduction in PASI (PASI 90) or PASI 90 plus a DLQI of 0/1. Sensitivity analysis using subgroup comparison and multiple imputation model yielded consistent conclusions.

CONCLUSIONS

The PtGA NRS showed good reliability, validity and responsiveness in patients with psoriasis, and was feasible in clinical trials and daily practice.

Comprehensive Assessment of Reading in Aphasia (CARA) reading questionnaire-German version

BACKGROUND

Reading comprehension is frequently impaired in persons with aphasia (PWA). For goal-setting and outcome measurement, speech and language therapists (SLTs) need to determine an individual's perspective of their reading difficulties and everyday reading activities. The Comprehensive Assessment of Reading in Aphasia (CARA) reading questionnaire provides a person-centred tool to find out the individual perception of reading functions, reading-related emotions and reading activities in PWA. It was developed and evaluated in English. So far, there is no equivalent instrument in German.

AIMS

To translate and adapt the CARA reading questionnaire into German language and culture, to evaluate its practicability and acceptance, and to provide the first psychometric properties of the German version.

METHODS & PROCEDURES

Based on translation and adaptation guidelines, we conducted two forward translations that were merged and then adapted. A back translation was prepared and compared with the original version. It was found to be semantically equivalent by one of the authors of the original version. We performed pilot testing with 12 PWA, and the pilot version was adapted according to the comments of these participants. We then collected data on self-reported perception of reading and on psychometric properties of the translated and adapted German version. A total of 22 German-speaking PWA completed the questionnaire at least five times during an intervention study. We analysed retest reliability with Spearman correlation, internal consistency with Cronbach's alpha, internal responsiveness with the standardized response mean, as well as the relationship between outcomes of the questionnaire and text comprehension measures using repeated measures correlations.

OUTCOMES & RESULTS

Our data suggest good practicability and acceptance of the German version of the CARA reading questionnaire as well as appropriate validity, reliability and sensitivity to measure therapy-induced change. We found moderate correlations between outcomes of the questionnaire and text-level reading speed.

CONCLUSIONS & IMPLICATIONS

The German version of the CARA reading questionnaire could be helpful in intervention planning and goal-setting with German-speaking PWA. By using the questionnaire, SLTs can find out about a person's individual perception of reading difficulties as well as individually relevant reading activities. The questionnaire provides a tool to measure change and is therefore valuable to demonstrate self-reported individual progress. As reading speed seems to be an indicator of personal perception of reading difficulty, it is important to consider reading speed in reading interventions and in reading comprehension assessments.

WHAT THIS PAPER ADDS

What is already known on the subject Reading comprehension is frequently impaired in PWA. Reading preferences, the perception of difficulties and the impact on everyday life reading activities are specific to the individual and thus need to be known for goal-setting, intervention planning and monitoring of change. As part of a comprehensive assessment of reading, Morris et al. developed a person-centred English language questionnaire for this purpose. So far, there is no equivalent tool in German. What this paper adds to the existing knowledge In this study, we translated and adapted the questionnaire to German language and culture, and analysed its validity and reliability with German-speaking PWA. We demonstrated that the German version is accessible for German-speaking PWA, and that it has appropriate validity, reliability and sensitivity to measure self-reported change. Outcomes of the questionnaire correlate with text level reading speed. What are the potential or actual clinical implications of this work? The German version of the questionnaire could be a valuable self-reported outcome measure to assess individual perceptions of reading and to measure progress (as perceived by an individual) as a consequence of recovery or intervention in either clinical or research settings. As reading speed might be an indicator of everyday life reading as perceived by an individual, it should be considered in reading assessments and interventions.

Psychometric evaluation of a quality of recovery score for the postanesthesia care unit-A preliminary validation study

INTRODUCTION

Patients' perception of postoperative recovery is a key aspect of perioperative care. Self-reported quality of recovery (QoR) has evolved as a relevant endpoint in perioperative research. Several psychometric instruments have been introduced to assess self-reported recovery 24 hours after surgery. However, there is no questionnaire suitable for use in the postanesthesia care unit (PACU). We aimed to develop and psychometrically evaluate a QoR questionnaire for the PACU (QoR-PACU).

METHODS

The QoR-PACU was developed in German language based on the 40-item QoR-40 questionnaire. Between March and November 2020, adult patients scheduled for elective urologic surgery completed the QoR-PACU preoperatively and during the PACU stay. We evaluated feasibility, validity, reliability, and responsiveness.

RESULTS

We included 375 patients. After two piloting phases including 72 and 48 patients, respectively, we administered the final version of the QoR-PACU to 255 patients, with a completion rate of 96.5%. Patients completed the QoR-PACU at a median of 125.0 (83.0; 156.8) min after arrival in the PACU. Construct validity was good with postoperative QoR-PACU sum scores correlating with age (r = 0.23, 95% CI: 0.11 to 0.35, p < 0.001), length of PACU stay (r = -0.15, 95%CI: -0.27 to -0.03, p = 0.02), pain in the PACU (r = -0.48, 95% CI: -0.57 to -0.37, p < 0.001) and piritramide dose administered (r = -0.29, 95% CI: -0.40 to -0.17, p < 0.001). Cronbach's alpha was 0.67 (95% CI: 0.61-0.73) with moderate test-retest reliability (ICC of 0.67, 95% CI: 0.38 to 0.83). Cohen's effect size was 3.08 and the standardized response mean was 1.65 indicating adequate responsiveness.

CONCLUSION

The assessment of QoR in the early postoperative period is feasible. We found high acceptability, good validity, adequate responsiveness, and moderate reliability. Future studies should evaluate the psychometric properties of the QoR-PACU in more heterogeneous patient populations including female and gender-diverse patients with varying degress of perioperative risk.

Construct validity and responsiveness of a health-related symptom index for persons either treated or monitored for anal high-grade squamous intraepithelial lesions (HSIL): AMC-A01/-A03

PURPOSE

To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI).

METHODS

The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization.

RESULTS

Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness.

CONCLUSION

A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making.

Measuring health-related quality of life in sarcopenia: summary of the SarQoL psychometric properties

Patient perspectives are now widely recognized as a key element in the evaluation of health interventions. Therefore, the provision of specific and validated Patient Reported Outcome Measures that emphasize the lived experience of patients suffering from specific diseases is very important. In the field of sarcopenia, the only validated specific health-related quality of life (HRQoL) instrument available is the Sarcopenia Quality of Life questionnaire (SarQoL). This self-administrated HRQoL questionnaire, developed in 2015, consists of 55 items arranged into 22 questions and has currently been translated into 35 languages. Nineteen validation studies performed on SarQoL have consensually confirmed the capacity of SarQoL to detect difference in HRQoL between older people with and without sarcopenia, its reliability and its validity. Two further observational studies have also indicated its responsiveness to change. A short form SarQoL, including only 14 items has further been developed and validated to reduce the potential burden of administration. Research on the psychometric properties of SarQoL questionnaire is still encouraged as the responsiveness to change of SarQoL has not yet been measured in the context of interventional studies, as limited prospective data currently exist and as there is still not cut-off score to define a low HRQoL. In addition, SarQoL has mainly been used in community-dwelling older individuals with sarcopenia and would benefit to be studied in other types of populations. This review aims to provide to researchers, clinicians, regulators, pharmaceutical industries and other stakeholders a clear summary of comprehensive evidence on the SarQoL questionnaire published up to January 2023Query.

How Much Does Presenteeism Change in Response to Interventions or Alterations in Health Status? A Systematic Review and Meta-Analysis Using the COSMIN Methodology

Purpose The purpose of this study was to estimate the extent to which measures of presenteeism among workers change in response to alterations in health status induced by treatment or natural history. Methods We searched eight databases in August 2020 for studies published since 2012 measuring presenteeism longitudinally. Two independent reviewers screened the titles, abstracts, and full-text articles and performed data extraction. Studies were stratified into longitudinal studies using presenteeism as an outcome and measurement studies designed to test the responsiveness of presenteeism measures. We appraised the methodological quality of the measurement studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist. Standardized response means (SRMs) for interventional studies where participants reported improvement on anchor measures were quantitatively pooled.Results Our searches returned 2882 results. Eleven measurement studies and 126 longitudinal studies were included. Of the measurement studies (n = 2625 participants), 7 had adequate study quality and 4 studies were deemed doubtful. Anchors and responsiveness methods varied considerably. Our estimate of responsiveness from 5 measurement studies and 4 presenteeism measures is an SRM of 0.85 (95% CI 0.77, 0.92) and Cohen's d of 0.54 (95% CI 0.49, 0.58), translating to an average important change of 17/100. For deterioration, the value is - 17/100. Conclusions We found considerable variation regarding how responsiveness data was reported in measurement studies. There is evidence that responsiveness is strong for four presenteeism measures: the Work Productivity Survey, the Work Functioning Impairment Scale, the Work Role Functioning Questionnaire, and the Nurses Work Functioning Questionnaire.

Responsiveness to change in health status of the EQ-5D in patients treated for depression and anxiety

BACKGROUND

The EQ-5D is a commonly used generic measure of health but evidence on its responsiveness to change in mental health is limited. This study aimed to explore the responsiveness of the five-level version of the instrument, the EQ-5D-5 L, in patients receiving treatment for depression and anxiety.

METHODS

Patient data (N = 416) were collected at baseline and at end of treatment in an observational study in a Norwegian outpatient clinic. Patients were adults of working age (18-69 years) and received protocol-based metacognitive or cognitive therapy for depression or anxiety according to diagnosis. Responsiveness in the EQ-5D was compared to change in the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). Effect sizes (Cohen's d), Standardised response mean (SRM), and Pearson's correlation were calculated. Patients were classified as "Recovered", "Improved", or "Unchanged" during treatment using the BDI-II and the BAI. ROC analyses determined whether the EQ-5D could correctly classify patient outcomes.

RESULTS

Effect sizes were large for the BAI, the BDI-II, the EQ-5D value and the EQ VAS, ranging from d = 1.07 to d = 1.84. SRM were also large (0.93-1.67). Pearson's correlation showed strong agreement between change scores of the EQ-5D value and the BDI-II (r_s -0.54) and moderate between the EQ-5D value and the BAI (r_s -0.43). The EQ-5D consistently identified "Recovered" patients versus "Improved" or "Unchanged" in the ROC analyses with AUROC ranging from 0.72 to 0.84.

CONCLUSION

The EQ-5D showed good agreement with self-reported symptom change in depression and anxiety, and correctly identified recovered patients. These findings indicate that the EQ-5D may be appropriately responsive to change in patients with depression and anxiety disorders, although replication in other clinical samples is needed.

Adaptation and multicentre validation of a patient-centred outcome scale for people severely ill with COVID (IPOS-COV)

BACKGROUND

Patient-centred measures to capture symptoms and concerns have rarely been reported in severe COVID. We adapted and tested the measurement properties of the proxy version of the Integrated Palliative care Outcome Scale-IPOS-COV for severe COVID using psychometric approach.

METHODS

We consulted experts and followed consensus-based standards for the selection of health status measurement instruments and United States Food and Drug Administration guidance for adaptation and analysis. Exploratory Factor Analysis and clinical perspective informed subscales. We tested the internal consistency reliability, calculated item total correlations, examined re-test reliability in stable patients, and also evaluated inter-rater reproducibility. We examined convergent and divergent validity of IPOS-COV with the Australia-modified Karnofsky Performance Scale and evaluated known-groups validity. Ability to detect change was examined.

RESULTS

In the adaptation phase, 6 new items were added, 7 items were removed from the original measure. The recall period was revised to be the last 12-24 h to capture fast deterioration in COVID. General format and response options of the original Integrated Palliative care Outcome Scale were preserved. Data from 572 patients with COVID from across England and Wales seen by palliative care services were included. Four subscales were supported by the 4-factor solution explaining 53.5% of total variance. Breathlessness-Agitation and Gastro-intestinal subscales demonstrated good reliability with high to moderate (a = 0.70 and a = 0.67) internal consistency, and item-total correlations (0.62-0.21). All except the Flu subscale discriminated well between patients with differing disease severity. Inter-rater reliability was fair with ICC of 0.40 (0.3-0.5, 95% CI, n = 324). Correlations between the subscales and AKPS as predicted were weak (r = 0.13-0.26) but significant (p < 0.01). Breathlessness-Agitation and Drowsiness-Delirium subscales demonstrated good divergent validity. Patients with low oxygen saturation had higher mean Breathlessness-Agitation scores (M = 5.3) than those with normal levels (M = 3.4), t = 6.4 (186), p < 0.001. Change in Drowsiness-Delirium subscale correctly classified patients who died.

CONCLUSIONS

IPOS-COV is the first patient-centred measure adapted for severe COVID to support timely management. Future studies could further evaluate its responsiveness and clinical utility with clinimetric approaches.

Comparing the effects of reduced social contact on psychosocial wellbeing before and during the COVID-19 pandemic: a longitudinal survey from two Norwegian counties

PURPOSE

To determine changes to people's social contact during COVID-19, and whether reduced social contact was associated with changes to psychosocial wellbeing.

METHODS

Questionnaire data were collected from a sample of adult respondents (18 years or more) in two Norwegian counties participating pre-COVID-19 (September 2019-February 2020; n = 20,196) and at two time points during COVID-19 (June [Mid] and November/December [Late] 2020; n = 11,953 and n = 10,968, respectively). The main outcome measures were participants' self-reported changes to social contact, loneliness, psychological distress, and life satisfaction.

RESULTS

The proportion of respondents reporting less social contact due to COVID-19 decreased from 62% in Mid-2020 to 55% in Late-2020. Overall, reported psychological wellbeing remained unchanged or improved from pre-COVID-19 to Mid-2020. From Mid-2020 to Late-2020, however, a reduction in psychological wellbeing was observed. Poorer psychological wellbeing was found for those with less social contact during the pandemic compared with people reporting unchanged social contact. This effect increased over time and was observed for all age groups at Late-2020. At Mid-2020, the importance of change in social contact for change in psychological wellbeing was greatest among young adults (< 30 years), while no significant differences were found for the oldest age group.

CONCLUSION

The association between COVID-19-era changes to social contact and loneliness, psychological distress, and life satisfaction is complex and appears to be age-dependent. Future studies should consider the quality of social contact and cultural contexts in which social restrictions are imposed.

The Sensitivity to Change of the ASAS Health Index in an Observational Real-Life Cohort Study

OBJECTIVE

The Assessment of Spondyloarthritis international Society Health Index (ASAS HI) measures global functioning and health in patients with axial spondyloarthritis (axSpA) covering domains of physical, emotional, and social functioning. The main aim of this study was to investigate the sensitivity to change of ASAS HI in comparison with established variables of disease activity, function, and mental health.

METHODS

Patients with axSpA from the disease register RABBIT-SpA with follow-up time of at least 12 months and available ASAS HI questionnaires were included. Patients received questionnaires addressing disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], Ankylosing Spondylitis Disease Activity Score [ASDAS]), physical function (Bath Ankylosing Spondylitis Functional Index [BASFI]), mental health (5-item World Health Organization Well-Being Index [WHO-5]), and global functioning (ASAS HI). Standardized response means (SRMs) were calculated to compare the sensitivity to change of different variables.

RESULTS

Six hundred and sixty-seven patients were included, 552 treated with biologic disease-modifying antirheumatic drugs (bDMARDs) and 115 with conventional synthetic DMARDs and/or nonsteroidal antiinflammatory drugs (control group). Between baseline and month 12, the mean ASAS HI declined from 6.9 to 5.1 in the bDMARD group and from 5.9 to 5.6 in the conventionally treated group. In the bDMARD group, the SRM of ASAS HI was 0.52, compared to 0.59 for BASFI, 0.65 for WHO-5, 0.73 for BASDAI, and 0.90 for ASDAS. The following ASAS HI domains were most frequently affected: pain (78% agreed), maintaining body position (75%), and energy/drive (73%). In the patients receiving bDMARDs, there was an improvement in all items. In the control group, the largest improvement was seen in pain.

CONCLUSION

As expected, ASDAS and BASDAI as disease activity scores showed high sensitivity to change, whereas changes in physical function (BASFI), mental health (WHO-5), and the broader concept of functioning and health (ASAS HI) were moderate.

Translation and Validation of the Turkish Version of the Quality of Postoperative Recovery Score QoR-15: A Multi-Centred Cohort Study

OBJECTIVE

The Quality of Recovery-15 questionnaire is a self-rated questionnaire used to assess the quality of the postoperative recovery and health status of patients in the early period following surgery. The aim of this study was to assess the reliability, validity, and responsiveness of the Turkish version of the Quality of Recovery-15.

METHODS

After approval by the Maltepe University local ethics committee, this observational study was conducted among patients who received surgical interventions at Mersin University Hospital between July 2019 and January 2020. Reliability, feasibility, and validity were assessed to validate the Turkish version of the Quality of Recovery-15.

RESULTS

The completion rate of the form was determined to be 92% and a total of 200 patients were enrolled in the study. The Cronbach's alpha of the global Turkish version of the Quality of Recovery-15 was 0.927. Test-retest reliability was 0.84 [CI 95%: 0.75-0.90] and Cohen's effect size was 0.319. The total standardized response mean was determined as 0.53.

CONCLUSIONS

This is the first study in which the Quality of Recovery-15 scale was translated into Turkish with our knowledge. The Turkish version of the Quality of Recovery-15 showed satisfactory reliability and validity in evaluating the quality of recovery after surgery in the Turkish population.

Bleaching efficacy and quality of life of different bleaching techniques - randomized controlled trial

OBJECTIVES

To evaluate bleaching efficacy and oral health-related quality of life (ORHQoL) of three bleaching systems with similar hydrogen peroxide (HP) concentration for up to 6 months post-treatment.

MATERIALS AND METHODS

A randomized controlled trial was designed with three parallel groups: group A - in-office 6% HP paint-on varnish; group B - at-home 6% HP with adaptable tray; group C - at-home 16% carbamide peroxide with custom tray. At three different stages (baseline, after bleaching, and 6-month follow-up), ORHQoL was evaluated by the OHIP-14 questionnaire and tooth color of the upper canines and central incisors were measured by two shade guides and a spectrophotometer (measuring CIE L*a*b* with respective color/whiteness differences - ΔE00/ΔWID). Results were presented as mean and 95% confidence intervals and statistical tests were performed appropriately, considering a significance level of α = 0.05.

RESULTS

All groups presented significant color differences (P < 0.05) between all stages, with ΔE00/ΔWID surpassing the perceptibility threshold in 98% cases, with group C's results being significantly (P < 0.05) higher when compared to other groups, although with significantly (P < 0.05) higher values of color relapse. Significative ORHQoL improvements (P < 0.05) were detected after bleaching in a global analysis with no differences between techniques.

CONCLUSIONS

All techniques presented bleaching efficacy, color stability, and improvements in ORHQoL up to 6 months post-treatment.

CLINICAL SIGNIFICANCE

Clinicians may consider both at-home and in-office bleaching techniques with 6% HP to attain long-lasting satisfactory clinical results while producing positive changes in ORHQoL.

Evaluation of measurement properties of the German Work Role Functioning Questionnaire

OBJECTIVE

We assessed the measurement properties of the German Work Role Functioning Questionnaire (WRFQ) after its cross-cultural adaptation of the Dutch version. The WRFQ is a generic role-specific instrument that measures how a particular health status influences the ability to meet work demands.

METHODS

We performed an observational study among German employees assessing the following measurement properties: 1) structural, 2) convergent and 3) discriminant validity, 4) floor and ceiling effects, 5) internal consistency, 6) reproducibility and 7) responsiveness. Participants were recruited from an online access panel sample aged 18 to 64 years having worked more than 12 hours in the last 4 weeks prior to study enrollment (n_(T0) = 653, n_(T1) = 66, n_(T2) = 95).

RESULTS

Measurement properties proved to be good except for structural validity and responsiveness. An exploratory factor analysis showed limited replicability of three of the four original subscales.

CONCLUSION

With the WRFQ German version, the extent can be measured, to which employees with a certain health level experience problems can meet their work demands. This widely used health-related work outcome measurement tool, that helps to identify employees with decreasing work functioning, is now also available in German. This gives researchers and practitioners the opportunity to address work functioning in practice, e.g. in intervention studies in occupational health or rehabilitation. Further research to examine valid subscales is needed.

Clinically Relevant Changes for Cognitive Outcomes in Preclinical and Prodromal Cognitive Stages: Implications for Clinical Alzheimer Trials

BACKGROUND AND OBJECTIVES

Identifying a clinically meaningful change in cognitive test score is essential when using cognition as an outcome in clinical trials. This is especially relevant because clinical trials increasingly feature novel composites of cognitive tests. Our primary objective was to establish minimal clinically important differences (MCIDs) for commonly used cognitive tests, using anchor-based and distribution-based methods, and our secondary objective was to investigate a composite cognitive measure that best predicts a minimal change in the Clinical Dementia Rating-Sum of Boxes (CDR-SB).

METHODS

From the Swedish BioFINDER cohort study, we consecutively included cognitively unimpaired (CU) individuals with and without subjective or mild cognitive impairment (MCI). We calculated MCIDs associated with a change of ≥0.5 or ≥1.0 on CDR-SB for Mini-Mental State Examination (MMSE), ADAS-Cog delayed recall 10-word list, Stroop, Letter S Fluency, Animal Fluency, Symbol Digit Modalities Test (SDMT) and Trailmaking Test (TMT) A and B, and triangulated MCIDs for clinical use for CU, MCI, and amyloid-positive CU participants. For investigating cognitive measures that best predict a change in CDR-SB of ≥0.5 or ≥1.0 point, we conducted receiver operating characteristic analyses.

RESULTS

Our study included 451 cognitively unimpaired individuals, 90 with subjective cognitive decline and 361 without symptoms of cognitive decline (pooled mean follow-up time 32.4 months, SD 26.8, range 12-96 months), and 292 people with MCI (pooled mean follow-up time 19.2 months, SD 19.0, range 12-72 months). We identified potential triangulated MCIDs (cognitively unimpaired; MCI) on a range of cognitive test outcomes: MMSE -1.5, -1.7; ADAS delayed recall 1.4, 1.1; Stroop 5.5, 9.3; Animal Fluency: -2.8, -2.9; Letter S Fluency -2.9, -1.8; SDMT: -3.5, -3.8; TMT A 11.7, 13.0; and TMT B 24.4, 20.1. For amyloid-positive CU, we found the best predicting composite cognitive measure included gender and changes in ADAS delayed recall, MMSE, SDMT, and TMT B. This produced an AUC of 0.87 (95% CI 0.79-0.94, sensitivity 75%, specificity 88%).

DISCUSSION

Our MCIDs may be applied in clinical practice or clinical trials for identifying whether a clinically relevant change has occurred. The composite measure can be useful as a clinically relevant cognitive test outcome in preclinical AD trials.

Meaningful values of the EQ-5D-3L in patients undergoing primary knee arthroplasty

AIMS

The aim of this study was to report the meaningful values of the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS) in patients undergoing primary knee arthroplasty (KA).

METHODS

This is a retrospective study of patients undergoing primary KA for osteoarthritis in a university teaching hospital (Royal Infirmary of Edinburgh) (1 January 2013 to 31 December 2019). Pre- and postoperative (one-year) data were prospectively collected for 3,181 patients (median age 69.9 years (interquartile range (IQR) 64.2 to 76.1); females, n = 1,745 (54.9%); median BMI 30.1 kg/m² (IQR 26.6 to 34.2)). The reliability of the EQ-5D-3L was measured using Cronbach's alpha. Responsiveness was determined by calculating the anchor-based minimal clinically important difference (MCID), the minimal important change (MIC) (cohort and individual), the patient-acceptable symptom state (PASS) predictive of satisfaction, and the minimal detectable change at 90% confidence intervals (MDC-90).

RESULTS

The EQ-5D-3L demonstrated good internal consistency with an overall Cronbach alpha of 0.75 (preoperative) and 0.88 (postoperative), respectively. The MCID for the Index score was 0.085 (95% confidence interval (CI) 0.042 to 0.127) and EQ-VAS was 6.41 (95% CI 3.497 to 9.323). The MIC_COHORT was 0.289 for the EQ-5D and 5.27 for the EQ-VAS. However, the MIC_INDIVIDUAL for both the EQ-5D-3L Index (0.105) and EQ-VAS (-1) demonstrated poor-to-acceptable reliability. The MDC-90 was 0.023 for the EQ-5D-3L Index and 1.0 for the EQ-VAS. The PASS for the postoperative EQ-5D-3L Index and EQ-VAS scores predictive of patient satisfaction were 0.708 and 77.0, respectively.

CONCLUSION

The meaningful values of the EQ-5D-3L Index and EQ-VAS scores can be used to measure clinically relevant changes in health-related quality of life in patients undergoing primary KA.Cite this article: Bone Joint Res 2022;11(9):619-628.

Effects of a Cognitively Challenging Agility Boot Camp Program on Balance and Gait in People With Parkinson's Disease: Does Freezing of Gait Status Matter?

BACKGROUND AND AIM

Individuals with Parkinson's disease (PD) with and without freezing of Gait (FoG) may respond differently to exercise interventions for several reasons, including disease duration. This study aimed to determine whether both people with and without FoG benefit from the Agility Boot Camp with Cognitive Challenges (ABC-C) program.

METHODS

This secondary analysis of our ABC-C trial included 86 PD subjects: 44 without FoG (PD-FoG) and 42 with FoG (PD + FoG). We collected measures of standing sway balance, anticipatory postural adjustments, postural responses, and a 2-minute walk with and without a cognitive task. Two-way repeated analysis of variance, with disease duration as covariate, was used to investigate the effects of ABC-C program. Effect sizes were calculated using standardized response mean (SRM) for PD-FoG and PD + FoG, separately.

RESULTS

The ABC-C program was effective in improving gait performance in both PD-FoG and PD + FoG, even after controlling for disease duration. Specifically, dual-task gait speed (P < .0001), dual-cost stride length (P = .012), and these single-task measures: arm range of motion (P < .0001), toe-off angle (P = .005), gait cycle duration variability (P = .019), trunk coronal range of motion (P = .042), and stance time (P = .046) improved in both PD-FoG and PD + FoG. There was no interaction effect between time (before and after exercise) and group (PD-FoG/PD + FoG) in all 24 objective measures of balance and gait. Dual-task gait speed improved the most in PD + FoG (SRM = 1.01), whereas single-task arm range of motion improved the most in PD-FoG (SRM = 1.01).

CONCLUSION

The ABC-C program was similarly effective in improving gait (and not balance) performance in both PD-FoG and PD + FoG.

A comprehensive urban programme to reduce energy poverty and its effects on health and wellbeing of citizens in six European countries: study protocol of a controlled trial

Background

Nearly 11% of the European population is affected by energy poverty. Energy poverty is defined by the European Commission (2016) as the inability to afford basic energy services to guarantee a decent standard of living. Energy poverty is considered a complex, multidimensional problem that affects environment, housing, urban development, and health. Living in energy poverty conditions is associated with poorer human health and wellbeing. Hence, the WELLBASED intervention programme aims to design, implement and evaluate a comprehensive urban programme, based on the social-ecological model, to reduce energy poverty and its effects on the citizens’ health and wellbeing in six European urban study sites: Valencia, Spain; Heerlen, The Netherlands; Leeds, United Kingdom; Edirne, Turkey; Obuda, Hungary, and; Jelgava, Latvia.

Methods

A controlled trial is performed. A total of 875 participants are recruited (125–177 per study site) to receive the WELLBASED intervention programme for 12 months (intervention condition) and 875 participants act as controls (control condition). Data will be collected with a baseline measurement at inclusion (T0), and follow-up measurements after 6 months (T1), 12 months (T2), and 18 months (T3). In both study arms, effects of the WELLBASED intervention programme are measured: health-related quality of life (HR-QoL), mental health, frailty in older adults, self-perceived health, chronic conditions, and care utilization. At the same time points, household expenditure on energy and energy consumption are obtained. In the intervention arm, health-monitoring data (i.e. peak flow, oxygen saturation, blood pressure, and heart rate) are obtained monthly and sleep quality with a three-month interval. Household data with regard to temperature, humidity and air quality are collected near real-time by home sensors. Qualitative interviews are conducted in each study site to evaluate the impacts of the WELLBASED intervention programme and to help explain findings.

Discussion

The WELLBASED intervention programme will provide new insights into the effectiveness of a comprehensive urban programme to tackle energy poverty and its effects on health and wellbeing across Europe. Hence, this study can contribute to European-wide replicable solutions for policy-makers and city practitioners to alleviate energy poverty.

Trial registration

ISRCTN registry number is ISRCTN14905838. Date of registration is 15/02/2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13968-2.

'Value-based methodology for person-centred, integrated care supported by Information and Communication Technologies' (ValueCare) for older people in Europe: study protocol for a pre-post controlled trial

Background

Older people receive care from multiple providers which often results in a lack of coordination. The Information and Communication Technology (ICT) enabled value-based methodology for integrated care (ValueCare) project aims to develop and implement efficient outcome-based, integrated health and social care for older people with multimorbidity, and/or frailty, and/or mild to moderate cognitive impairment in seven sites (Athens, Greece; Coimbra, Portugal; Cork/Kerry, Ireland; Rijeka, Croatia; Rotterdam, the Netherlands; Treviso, Italy; and Valencia, Spain). We will evaluate the implementation and the outcomes of the ValueCare approach. This paper presents the study protocol of the ValueCare project; a protocol for a pre-post controlled study in seven large-scale sites in Europe over the period between 2021 and 2023.

Methods

A pre-post controlled study design including three time points (baseline, post-intervention after 12 months, and follow-up after 18 months) and two groups (intervention and control group) will be utilised. In each site, (net) 240 older people (120 in the intervention group and 120 in the control group), 50–70 informal caregivers (e.g. relatives, friends), and 30–40 health and social care practitioners will be invited to participate and provide informed consent. Self-reported outcomes will be measured in multiple domains; for older people: health, wellbeing, quality of life, lifestyle behaviour, and health and social care use; for informal caregivers and health and social care practitioners: wellbeing, perceived burden and (job) satisfaction. In addition, implementation outcomes will be measured in terms of acceptability, appropriateness, feasibility, fidelity, and costs. To evaluate differences in outcomes between the intervention and control group (multilevel) logistic and linear regression analyses will be used. Qualitative analysis will be performed on the focus group data.

Discussion

This study will provide new insights into the feasibility and effectiveness of a value-based methodology for integrated care supported by ICT for older people, their informal caregivers, and health and social care practitioners in seven different European settings.

Trial registration

ISRCTN registry number is 25089186. Date of trial registration is 16/11/2021.

Validation of the parent global assessment as a health-related quality of life measure in juvenile idiopathic arthritis: results from ReACCh-Out

OBJECTIVES

To (i) validate the JIA parent global assessment (parent global) as a health-related quality of life (HRQoL) instrument; (ii) evaluate measurement properties of accepted HRQoL measures relative to those of the parent global; and (iii) assess causal pathways determining parent global scores.

METHODS

Data from the Research in Arthritis in Canadian Children emphasizing outcomes (ReACCh-Out) cohort were used. Measurement properties were assessed in 344 patients at enrolment and 6 months later. Causal pathways were tested by structural equation modelling to understand root causes and mediators leading to parent global scores.

RESULTS

Construct validity was supported by Spearman correlations of 0.53-0.70 for the parent global with the Juvenile Arthritis Quality of Life Questionnaire, Quality of My Life health scale (HRQoML), Pediatric Quality of Life Inventory (PedsQL)-Parent, and Child Health Questionnaire (CHQ)-Physical. Exceptions were PedsQL-Child (0.44) and CHQ-Psychosocial (0.31). Correlations were lower (0.14-0.49) with disease activity measures (physician global assessment of disease activity, active joint count, ESR). Responsiveness of the parent global to improvement according to parent ratings (0.51) was acceptable and within the range (0.32-0.71) of that of other measures. Reliability estimates and measurement errors for all measures were unsatisfactory, likely due to the prolonged time between assessments. Causal pathways for the parent global matched those previously reported for HRQoML.

CONCLUSIONS

Our results offer support for the parent global as a valid measure of HRQoL for JIA. If confirmed, existing studies using the parent global may be re-interpreted, enhancing our knowledge of HRQoL in children with JIA.

Effects of MAO-B inhibitors on non-motor symptoms and quality of life in Parkinson's disease: A systematic review

Non-motor symptoms (NMS) are common among patients with Parkinson's disease and reduce patients' quality of life (QOL). However, there remain considerable unmet needs for NMS management. Three monoamine oxidase B inhibitors (MAO-BIs), selegiline, rasagiline, and safinamide, have become commercially available in many countries. Although an increasing number of studies have reported potential beneficial effects of MAO-BIs on QOL and NMS, there has been no consensus. Thus, the primary objective of this study was to provide an up-to-date systematic review of the QOL and NMS outcomes from the available clinical studies of MAO-BIs. We conducted a literature search using the PubMed, Scopus, and Cochrane Library databases in November 2021. We identified 60 publications relevant to this topic. Overall, rasagiline and safinamide had more published evidence on QOL and NMS changes compared with selegiline. This was likely impacted by selegiline being introduced many years prior to the field embarking on the study of NMS. The impact of MAO-BIs on QOL was inconsistent across studies, and this was unlikely to be clinically meaningful. MAO-BIs may potentially improve depression, sleep disturbances, and pain. In contrast, cognitive and olfactory dysfunctions are likely unresponsive to MAO-BIs. Given the paucity of evidence and controlled, long-term studies, the effects of MAO-BIs on fatigue, autonomic dysfunctions, apathy, and ICD remain unclear. The effects of MAO-BIs on static and fluctuating NMS have never been investigated systematically. More high-quality studies will be needed and should enable clinicians to provide personalized medicine based on a non-motor symptom profile.

The acute effects of higher versus lower load duration and intensity on morphological and mechanical properties of the healthy Achilles tendon: a randomized crossover trial

The Achilles tendon (AT) exhibits volume changes related to fluid flow under acute load which may be linked to changes in stiffness. Fluid flow provides a mechanical signal for cellular activity and may be one mechanism that facilitates tendon adaptation. This study aimed to investigate whether isometric intervention involving a high level of load duration and intensity could maximize the immediate reduction in AT volume and stiffness compared with interventions involving a lower level of load duration and intensity. Sixteen healthy participants (12 males, 4 females; age 24.4±9.4 years, body mass 70.9±16.1 kg, height 1.7±0.1 m) performed three isometric interventions of varying levels of load duration (2 s and 8 s) and intensity (35% and 75% maximal voluntary isometric contraction) over a 3 week period. Freehand 3D ultrasound was used to measure free AT volume (at rest) and length (at 35%, 55% and 75% of maximum plantarflexion force) pre- and post-interventions. The slope of the force–elongation curve over these force levels represented individual stiffness (N mm⁻¹). Large reductions in free AT volume and stiffness resulted in response to long-duration high-intensity loading whilst less reduction was produced with a lower load intensity. In contrast, no change in free AT volume and a small increase in AT stiffness occurred with lower load duration. These findings suggest that the applied load on the AT must be heavy and sustained for a long duration to maximize immediate volume reduction, which might be an acute response that enables optimal long-term tendon adaptation via mechanotransduction pathways.

Summary: High levels of load duration and intensity have the greatest acute effect on the free Achilles tendon volume and stiffness.

Responsiveness and Validity of Weight-Bearing Test for Measuring Loading Capacity in Patients With Triangular Fibrocartilage Complex Injury

CONTEXT

Weight-bearing test (WBT) is a noninvasive quantitative test which has been used recently to determine loading capability of the individuals. The aim of this study was to strengthen the evidence for using the WBT test for measuring weight-bearing capacity of the upper-extremity with the specific objective of examining the internal and external responsiveness and concurrent validity of the test in patients with triangular fibrocartilage complex injury.

DESIGN

Single-group repeated measures.

METHODS

Internal responsiveness was assessed using effect size statistics. The correlation coefficient was used to examine external responsiveness by testing 5 hypotheses regarding predefined correlations between the changes in the measurements. Concurrent validity was evaluated by analyzing correlations between the WBT and other measurements. Thirty-one patients with triangular fibrocartilage complex injury were included for the analysis of the concurrent validity. Eighteen patients who completed all measurements at baseline and at 3-month follow-up enrolled for the responsiveness analysis. Measurements included the WBT, pain intensity, grip strength, and upper extremity functional level.

RESULTS

The WBT test was able to detect statistically significant changes in weight-bearing capacity between baseline and follow-up (P = .0001). The effect size of the WBT was large. Three out of 5 hypotheses (60%) were confirmed, a good correlation was found between changes scores of the WBT and grip strength (r = .478; P < .05). There were significant correlations between the WBT and other measurements (r value range from -.401 to .742; P < .05). A higher correlation was found between the WBT and grip strength (r = .742; P = .0001).

CONCLUSIONS

The responsiveness and concurrent validity of the WBT test confirmed that it is able to measure change in weight-bearing capacity in patients with triangular fibrocartilage complex injury.

Robot Fully Assisted Upper-Limb Functional Movements Against Gravity to Drive Recovery in Chronic Stroke: A Pilot Study

Background

Stroke is becoming more and more a disease of chronically disabled patients, and new approaches are needed for better outcomes. An intervention based on robot fully assisted upper-limb functional movements is presented.

Objectives

To test the immediate and sustained effects of the intervention in reducing impairment in chronic stroke and to preliminarily verify the effects on activity.

Methodology

Nineteen patients with mild-to-severe impairment underwent 12 40-min rehabilitation sessions, 3 per week, of robot-assisted reaching and hand-to-mouth movements. The primary outcome measure was the Fugl-Meyer Assessment (FMA) at T1, immediately after treatment (n = 19), and at T2, at a 6-month follow-up (n = 10). A subgroup of 11 patients was also administered the Wolf Motor Function Test Time (WMFT TIME) and Functional Ability Scale (WMFT FAS) and Motor Activity Log (MAL) Amount Of Use (AOU), and Quality Of Movement (QOM).

Results

All patients were compliant with the treatment. There was improvement on the FMA with a mean difference with respect to the baseline of 6.2 points at T1, after intervention (n = 19, 95% CI = 4.6–7.8, p < 0.0002), and 5.9 points at T2 (n = 10, 95% CI = 3.6–8.2, p < 0.005). Significant improvements were found at T1 on the WMFT FAS (n = 11, +0.3/5 points, 95% CI = 0.2–0.4, p < 0.004), on the MAL AOU (n = 11, +0.18/5, 95% CI = 0.07–0.29, p < 0.02), and the MAL QOM (n = 11, +0.14/5, 95% CI = 0.08–0.20, p < 0.02).

Conclusions

Motor benefits were observed immediately after intervention and at a 6-month follow-up. Reduced impairment would appear to translate to increased activity. Although preliminary, the results are encouraging and lay the foundation for future studies to confirm the findings and define the optimal dose-response curve.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: NCT03208634.

Test-Retest Reliability and Sensitivity to Change of Ultrasound-Based Methods of Measuring Synovial Inflammation in Knee Osteoarthritis

OBJECTIVES

To assess test-retest reliability of musculoskeletal ultrasound (US) measures of inflammation in patients with knee osteoarthritis (OA) and to assess the sensitivity to change of US measures of inflammation in patients with knee OA.

METHODS

To mimic a common clinical scenario, 36 patients (n = 70 knees) with symptomatic knee OA who were in stable condition underwent 2 assessments within 14 days by different operators and different US machines, graded by a single rater. Test-retest reliability was measured using Cohen's kappa coefficient, intraclass correlation coefficient (ICC), and absolute agreement parameters. A total of 51 patients (n = 72 knees) were tested immediately before and 21-28 days after intraarticular glucocorticoid injection to investigate sensitivity to change and longitudinal construct validity. Paired t-tests and standardized response mean (SRM) were used to assess sensitivity to change. Multivariate linear regression was used to investigate longitudinal construct validity of US with Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scores, while adjusting for covariates.

RESULTS

US measures of inflammation demonstrated moderate (κ = 0.41, 0.60) to substantial (κ = 0.61, 0.80) agreement. Quantitative measures of synovitis and effusion demonstrated good test-retest reliability (ICC_2,1 0.71, 0.92). US measures of synovitis and effusion demonstrated low-to-moderate sensitivity to change (SRM -0.29, -0.50). The associations between changes in US measures and KOOS pain scores over time were low, and 95% confidence intervals included zero.

CONCLUSION

In a clinical setting, US measures of inflammatory features of knee OA have substantial reliability and low-to-moderate sensitivity to change, whereas measures of structural OA features are less reliable. Longitudinal construct validity of US measures of synovitis and effusion to KOOS pain scores is not strongly supported.

Quantitative evaluation of upper limb ataxia in spinocerebellar ataxias

Objective

To quantitatively evaluate upper limb ataxia using a novel pen‐like sensor device in patients with spinocerebellar ataxia (SCA) and to assess its validity, reliability, and sensitivity to disease progression.

Methods

We designed a cross‐sectional and longitudinal study of patients with SCA and healthy controls. Upper limb ataxia was evaluated using a device that measures the three‐dimensional position every 10 msec. Participants were instructed to move a pen‐like part of the device iteratively between two buttons. We evaluated the time, length, velocity, and variation coefficient of the stroke, and calculated the distortion index using the mean squared error. The following scales were also evaluated: Scale for the Assessment and Rating of Ataxia (SARA), the International Cooperative Ataxia Rating Scale (ICARS), and the nine‐hole pegboard test. Subjects were followed 12 months after the baseline evaluation.

Results

A total of 42 patients with SCA and 33 healthy controls were enrolled and evaluated. For all ataxia indices measured using the device there were significant differences between healthy controls and patients with SCA. Among the ataxia indices, the distortion index showed the strongest correlation with the SARA and ICARS upper limb score (Pearson's r = 0.647 and 0.722, respectively). Test–retest reliability was high for most of the ataxia indices. In the longitudinal analysis, the distortion index showed high standardized response mean and adjusted effect size, regardless of disease severity.

Interpretation

Our study demonstrated that the distortion index is a reliable functional marker that is sensitive to longitudinal change in patients with SCA.

Oral Health-Related Quality of Life Changes in Patients with Dentofacial Deformities Class II and III after Orthognathic Surgery: A Systematic Review and Meta-Analysis

Our aim was to assess the impact of combined orthodontic–surgical treatment on patients’ oral health-related quality of life (OHRQoL) according to type of dentofacial deformities, by synthesizing the available evidence. Methods: Search was conducted in the PubMed, Embase/MEDLINE, Scopus, and Cochrane databases. The eligibility criteria were studies that measured OHRQoL before–after orthognathic surgery, with results disaggregated by Class II and III. Two researchers independently performed the selection process, data extraction, and methodological quality assessment. Meta-analysis of the standard mean differences (SMD) was performed using random effect models. Results: The search identified 1047 references. Thirteen studies met the inclusion criteria, and four were included in the meta-analysis. The SMD of OHRQL global score showed large improvement 4–7 months after surgery in Class II and III patients (2.09, 95% CI 0.68 to 3.49 and 1.96, 95% CI 1.22 to 2.70, respectively). The sensitivity analyses, excluding studies with weak methodological quality, showed that Class III patients’ improvement in functional limitation was significantly higher than in Class II patients (SMD 0.57, 95% CI 0.12–1.02). Conclusions: There is not enough evidence to support differences between Class II and III patients in the OHRQoL impact after orthognathic surgery, but findings suggest lower improvement of some domains in Class II patients.

Value of Global Longitudinal Strain for Identification and Monitoring of Left Ventricular Dysfunction in Becker Muscular Dystrophy

Cardiac involvement is the main cause of death in Becker muscular dystrophy (BMD). Identification of left ventricular (LV) function is crucial, but standard echocardiographic measurements such as LV ejection fraction (LVEF) might not be sensitive enough to detect early myocardial dysfunction. We explored the value of LV global longitudinal strain (GLS) as a more accurate echocardiographic parameter to detect and monitor LV dysfunction in BMD. Furthermore, we studied possible factors associated with LV dysfunction and progression. A total of 40 patients with BMD (age 39.0 ± 13.2 years) and 21 matched controls were included. Clinical variables, pulmonary tests, serum biomarkers, and echocardiograms were collected at baseline and after 2 years. LV systolic function was assessed by LVEF and LV GLS; a significant progression in LV dysfunction was defined as an absolute LV GLS deterioration ≥15%. Responsiveness to cardiac disease progression was determined using standardized response means. Patients showed impaired LVEF and LV GLS compared with controls (p <0.001). Of interest, 31 patients (77.5%) showed impaired LV GLS (defined as greater than -18%), whereas only 24 patients (60%) had reduced LVEF. LV GLS and LVEF correlated with troponin I (ρ = 0.553 and -0.523) and N-terminal pro-b-type natriuretic peptide (ρ = 0.506 and -0.585), but not with skeletal muscle or pulmonary function. At follow-up (2.0 ± 0.5 years, n = 29), LV GLS worsened significantly (-1.3 ± 0.8%, p = 0.002, standardized response mean = 0.70, annually = 0.60%), whereas LVEF remained stable. No risk factors for LV dysfunction progression were identified. In BMD, LV GLS is frequently impaired and shows deterioration over time compared with LVEF. LV GLS could be used as a more sensitive parameter to identify and monitor LV dysfunction.

A questionnaire to assess eating behavior: Structure, validity and responsiveness of a new German eating behavior scale (SEV)

Numerous weight-loss interventions promoting healthy and weight-reducing eating behavior have been developed over the past years. To evaluate the effectiveness of such interventions for eating behavior change, short, validated and sensitive instruments are needed. In this study series, we developed and validated a new outcome measure to assess health-conscious and weight-controlling eating behavior for the evaluation of weight-loss interventions. The preliminary version of the German eating behavior scale (Skala zumErnährungsverhalten [SEV]) included 40 items. Three studies were conducted to (a) reduce the preliminary item pool, (b) investigate structural validity and internal consistency using exploratory and confirmatory factor analyses (EFA, CFA), as well as McDonald's ω, and (c) test construct validity with physiological and behavioral parameters. Responsiveness to change was also assessed after a 12-week weight-loss intervention. EFA indicated a two-factor solution with health-conscious (hc-EB) and weight-controlling eating behavior (wc-EB) as subscales, CFA confirmed the two-factor solution with acceptable model fit. Internal consistencies of both subscales were also acceptable to good (hc-EB: ω = 0.88; wc-EB: ω = 0.78). Significantly small to moderate correlations to the Healthy Eating Index (r = 0.51) as well as blood glucose (r = 0.31), blood lipids (r = 0.23), and vascular age (r = 0.31) were found, supporting the construct validity of the SEV and its subscales. Both subscales detected intervention-related changes in eating behavior among subjects of a weight-loss intervention with Standardized Response Means of 0.52 and 0.67, indicating good responsiveness of the SEV. In sum, findings provide evidence that the SEV is a valid and responsive measure to assess health-conscious and weight-controlling eating behavior.

Changes in health-related quality of life after orthognathic surgery: a multicenter study

Objective

To evaluate changes in general and oral health-related quality of life (HRQoL) in patients with dentofacial deformity undergoing orthognathic surgery, and whether these changes vary according to type of deformity.

Material and methods

This is a prospective longitudinal multicenter study of patients with dentofacial deformities (n = 90). The Orthognathic Quality of Life Questionnaire (OQLQ), Oral Health Impact Profile (OHIP-14), and Short-Form Health Survey version2 (SF-36v2) were self-completed by patients before surgery, 3 and 6 months after orthognathic surgery. Change was tested using paired t-test, and compared between Class II and Class III of dentofacial deformity by unpaired t-test. The magnitude of change was examined estimating the standardized response mean (SRM).

Results

The OQLQ and OHIP-14 showed statistically significant improvements 6 months after surgery, compared with the pre-surgical evaluation, but the SF-36v2 only in the physical component summary. The SRM was large in OQLQ oral function (-1.11) and dentofacial facial aesthetics (-0.76) dimensions, and moderate in most of OHIP-14 dimensions. Differences in mean change between Class II and III were statistically significant for global scores of OQLQ (-10.08 vs -20.30, p = 0.0271) and OHIP-14 (-3.79 vs -10.56, p = 0.0144).

Conclusions

A significant improvement was observed in oral HRQoL and in the physical component of general health in patients with dentofacial deformities Class II and III after orthognathic surgery. Improvement was greater among Class III than in Class II patients.

Clinical relevance

These results provide patients, oral health care professionals, and planners with valuable information to make evidence-based decisions and facilitate shared clinical decision-making, taking into account the patients’ perspective.

Measurement properties of the Nepali version of the Quick-DASH in patients with shoulder pain

PURPOSE

To examine the measurement properties of the Nepali version of the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH-NP).

MATERIALS AND METHODS

The Nepali DASH and Shoulder Pain and Disability Index (SPADI) were completed at baseline assessment, and again at follow-up with the Nepali Global Rating of Change (GROC-NP) score. The 11 items of the QuickDASH-NP were extracted from the DASH and tested for confirmatory factory analysis (CFA), exploratory factor analysis (EFA), internal consistency (α), item-total correlation (ITC), test-retest reliability (ICC), measurement errors, hypothesis testing (correlation with DASH and SPADI) and responsiveness (effect size-ES, standardised response mean-SRM).

RESULTS

A total of 156 participants completed questionnaires at baseline and 121 at follow-up with all questionnaires valid (no participant leaving more than one question blank). CFA suggested a poor fit for the single-factor model. The EFA demonstrated two factors with acceptable internal consistency (α = 0.79 and 0.75) for each factor. The test-retest reliability was excellent (ICC = 0.94; 95%CI:0.92-0.98), correlation was positive and very strong with the DASH-NP (r = 0.96) and strong with the SPADI-NP (r = 0.81). The Standard Error of Measurement was 2.83 and Smallest Detectable Change 7.84/100. The ES and SRM were moderate to high.

CONCLUSIONS

The QuickDASH-NP is reliable, valid, and able to detect change in shoulder symptoms among Nepali participants. It offers a short, easy to complete self-reporting tool for clinical use and research.

Impact of bifrontal home-based transcranial direct current stimulation in pain catastrophizing and disability due to pain in fibromyalgia: a randomized, double-blind sham-controlled study

This randomized, double-blind trial tested the hypothesis that twenty sessions of home-based anodal(a)-transcranial direct current stimulation (tDCS) (2mA for 20 min) bifrontal, with anodal on the left dorsolateral prefrontal cortex (l-DLPFC) would be better than sham-(s)-tDCS to reduce scores on Pain Catastrophizing Scale (PCS) and disability-related to pain (DRP) assessed by the Profile of Chronic Pain: Screen (PCP:S) (primary outcomes). Secondary outcomes were depressive symptoms, sleep quality, heat pain threshold (HPT), heat pain tolerance (HPTo), and serum brain-derived-neurotrophic-factor (BDNF). Forty-eight women with fibromyalgia, 30-65 years-old were randomized into 2:1 groups [a-tDCS (n=32) or s-tDCS (n=16)]. Post hoc analysis revealed that a-tDCS reduced the PCS total scores by 51.38% compared to 26.96% in s-tDCS, and a-tDCS reduced PCP:S total scores by 31.43% compared to 19.15% in s-tDCS. The a-tDCS improved depressive symptoms, sleep quality and increased the HPTo. The delta-value in the serum BDNF (mean post treatment end minus pre-treatment) was conversely correlated with the a-tDCS effect in pain catastrophizing. In contrast, the a-tDCS impact on reducing the DRP at the treatment end was positively associated with a reduction in the serum BDNF and improvement of depressive symptoms, sleep quality and pain catastrophizing symptoms. PERSPECTIVE: Home-based bifrontal tDCS with a-tDCS on the l-DLPFC are associated with a moderate effect size (ES) in the following outcomes: (i) Decreased rumination and magnification of pain catastrophizing. (ii) Improved the disability for daily activities due to fibromyalgia symptoms. Overall, these findings support the feasibility of self-applied home-based tDCS on DLPFC to improve fibromyalgia symptoms.

The Relationship Between Changes in Movement and Activity Limitation or Pain in People With Knee Osteoarthritis: A Systematic Review

OBJECTIVE

To report whether changes in knee joint movement parameters recorded during functional activities relate to change in activity limitation or pain after an exercise intervention in people with knee osteoarthritis (OA).

DESIGN

Etiology systematic review.

LITERATURE SEARCH

Four databases (MEDLINE, Embase, CINAHL, and AMED) were searched up to January 22, 2021.

STUDY SELECTION CRITERIA

Randomized controlled trials or cohort studies of exercise interventions for people with knee OA that assessed change in knee joint movement parameters (moments, kinematics, or muscle activity) and clinical outcomes (activity limitation or pain).

DATA SYNTHESIS

A descriptive synthesis of functional activities, movement parameters, and clinical outcomes.

RESULTS

From 3182 articles, 22 studies met the inclusion criteria, and almost all were of low quality. Gait was the only investigated functional activity. After exercise, gait parameters changed 26% of the time, and clinical outcomes improved 90% of the time. A relationship between group-level changes in gait parameters and clinical outcomes occurred 24.5% of the time. Two studies directly investigated an individual-level relationship, reporting only 1 significant association out of 8 correlations tested.

CONCLUSION

Most studies reported no change in gait-related movement parameters despite improvement in clinical outcomes, challenging the belief that changing movement parameters is always clinically important in people with knee OA. J Orthop Sports Phys Ther 2021;51(10):492-502. doi:10.2519/jospt.2021.10418.

The mapping of cortical activation by near-infrared spectroscopy might be a biomarker related to the severity of fibromyalgia symptoms

The delta value of oxyhemoglobin (Δ-HbO) determined by functional near-infrared spectroscopy at prefrontal cortex (PFC) and motor cortex (MC) based on primary (25 °C) and secondary (5 °C) thermal stimuli presented a larger peak latency at left MC in fibromyalgia than in controls. The difference between HbO concentration 15 s after the thermal stimuli ending and HbO concentration before the thermal stimuli onset (Δ-HbO*) at left PFC increased 47.82% in fibromyalgia and 76.66% in controls. This value had satisfactory discriminatory properties to differentiate cortical activation in fibromyalgia versus controls. A receiver operator characteristics (ROC) analysis showed the Δ-HbO* cutoffs of − 0.175 at left PFC and − 0.205 at right PFC offer sensitivity and specificity of at least 80% in screening fibromyalgia from controls. In fibromyalgia, a ROC analysis showed that these cutoffs could discriminate those with higher disability due to pain and more severe central sensitization symptoms (CSS). The ROC with the best discriminatory profile was the CSS score with the Δ-HbO* at left PFC (area under the curve = 0.82, 95% confidence interval = 0.61–100). These results indicate that cortical activation based on Δ-HbO* at left PFC might be a sensitive marker to identify fibromyalgia subjects with more severe clinical symptoms.

A comparison of six outcome measures across the recovery period after distal radius fixation-Which to use and when?

PURPOSE

Many standardized outcome measures exist to measure recovery after surgical fixation of distal radius fractures, however, choosing the optimal instrument is difficult. We evaluated responsiveness, ceiling/floor effects, and criterion validity over multiple time intervals across a 2-year follow-up period for six commonly used instruments.

METHODS

A total of 259 patients who received open reduction and internal fixation for distal radius fractures between 2012 and 2015 were recruited. Patients were administered the Patient-Rated Wrist Evaluation (PRWE), Shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), Green and O'Brien score (Cooney modification) (CGNO), Gartland and Werley score (Sarmiento modification) (SGNW), flexion-extension arc (FEArc), and grip fraction test (GripFrac) at 1.5, 3, 6, 12, and 24 months postoperatively. Responsiveness was evaluated by calculating standardized response means (SRM) and Cohen's d effect sizes (ES), and by correlating each instrument's change scores against those of QuickDASH and PRWE, which were also used as external comparators to assess criterion validity. Ceiling/floor effects were calculated for all measures at each time point.

RESULTS

SRM (1.5-24 months) were 1.81, 1.77, 1.43, 1.16, 2.23, 2.45 and ES (1.5-24 months) were 1.81, 1.82, 1.95, 1.31, 1.99 and 2.90 for QuickDASH, PRWE, CGNO, SGNW, FEArc, and GripFrac respectively. Spearman correlation coefficients against QuickDASH at 24 months were: 0.809, 0.248, 0.563, 0.285, and 0.318 for PRWE, CGNO, SGNW, FEArc, and GripFrac respectively. Significant (>15% of patients reaching maximum score) ceiling effects were observed before 6 months for PRWE and SGNW.

CONCLUSIONS

Our evidence supports the use of QuickDASH, PRWE, FEArc and GripFrac up to 6 months postsurgery, and QuickDASH and PRWE after 6 months.

LEVEL OF EVIDENCE

Level II.

Changes in Health Literacy during the first year following a kidney transplantation: Using the Health Literacy Questionnaire

OBJECTIVES

The study aimed to identify changes in health literacy (HL) and associated variables during the first year following a kidney transplantation.

METHODS

A total of 196 transplant recipients were included in a prospective follow-up study. The patients answered the Health Literacy Questionnaire (HLQ) at 5 days, 8 weeks, 6 and 12 months following the kidney transplantation. Mixed linear models were used to analyze changes in HL and backward elimination was used to identify variables associated with HL.

RESULTS

Two main patterns of change were identified: a) HL increased during the first 8 weeks of close follow-up and b) in several domains, the positive increase from 5 days to 8 weeks flattened out from 5 days to 6 and 12 months. Self-efficacy, transplant-related knowledge, and general health were core variables associated with HL.

CONCLUSIONS

Overall, HL increased during the 8 weeks of close follow-up following the kidney transplantation, while 6 months seem to be a more vulnerable phase. Furthermore, low self-efficacy, less knowledge, and low self-perceived health may represent vulnerable characteristics in patients.

PRACTICAL IMPLICATIONS

Future kidney transplant care should take into account patients' access to and appraisal of health information and social support, and draw attention to potentially vulnerable groups.