Pooled Minimal Clinically Important Differences of the Mini-Balance Evaluation Systems Test in Patients With Early Subacute Stroke: A Multicenter Prospective Observational Study

OBJECTIVE

Balance problems are common in patients with stroke, and the Mini-Balance Evaluation Systems Test (Mini-BESTest) is a reliable and valid assessment tool for measuring balance function. Determining the minimal clinically important difference (MCID) is crucial for assessing treatment effectiveness. This study aimed to determine the MCID of the Mini-BESTest in patients with early subacute stroke.

METHODS

In this prospective multicenter study, 53 patients with early subacute stroke undergoing rehabilitation in inpatient units were included. The mean age of the patients was 72.6 (SD = 12.2) years. The Mini-BESTest, which consists of 14 items assessing various aspects of balance function, including anticipatory postural adjustments, postural responses, sensory orientation, and dynamic gait, was used as the assessment tool. The global rating of change (GRC) scales completed by the participants and physical therapists were used as external anchors to calculate the MCID. The GRC scale measured subjective improvement in balance function, ranging from -3 (very significantly worse) to +3 (very significantly better), with a GRC score of ≥+2 considered as meaningful improvement. Four methods were used to calculate the MCID: mean of participants with GRC of 2, receiver operating characteristic-based method, predictive modeling method, and adjustment of the predictive modeling method based on the rate of improvement. From the MCID values obtained using these methods, a single pooled MCID value was calculated.

RESULTS

The MCID values for the Mini-BESTest obtained through the 4 methods ranged from 3.2 to 4.5 points when using the physical therapist's GRC score as the anchor but could not be calculated using the participant's GRC score. The pooled MCID value for the Mini-BESTest was 3.8 (95% CI = 2.9-5.0).

CONCLUSIONS

The Mini-BESTest MCID obtained in this study is valuable for identifying improvements in balance function among patients with early subacute stroke.

IMPACT

Determination of the MCID is valuable for evaluating treatment effectiveness. The study findings provide clinicians with practical values that can assist in interpreting Mini-BESTest results and assessing treatment effectiveness.

Despite Greater Improvement in Pain and Function Among Obese Patients Shortly After Total Knee Arthroplasty, There is No Difference in Patient-Reported Outcomes and Satisfaction Between Body Mass Index Classes at 1 Year Postoperatively

BACKGROUND

Although obesity may be associated with an increased risk of perioperative and postoperative complications after total knee arthroplasty (TKA), body mass index (BMI) cutoffs for TKA patient selection remain a controversial topic. This study aimed to investigate patient-reported outcomes, satisfaction, and pain among BMI classes at 3 months and 1 year following TKA.

METHODS

A total of 2,365 patients were categorized into Centers for Disease Control BMI classes according to preoperative values. The BMI distribution over the cohort demonstrated 7 underweight, 340 healthy weight, 731 overweight, 666 Class I, 391 Class II, and 230 Class III obesity. Preoperative and postoperative Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), satisfaction, and pain scores were compared by BMI class by Analysis of Variance with pairwise comparisons.

RESULTS

Preoperative KOOS JR scores and satisfaction scores were both significantly greater for healthy weight patients compared to Class III patients (P < .0001). However, KOOS JR, satisfaction, and pain did not vary by BMI class postoperatively. Changes in scores from baseline suggest larger improvements with increasing BMI class, where Class III patients reported the greatest improvements in KOOS JR (23.24 ± 15.67, P < .0001) and pain scores (-3.56 ± 2.65, P < .0001) at 90 days. Significantly greater improvement with increasing BMI was also present at 1-year postoperatively for KOOS JR scores. A total of 85.8% of Class III patients reached the Minimal Clinically Important Difference for KOOS JR at 90 days compared to 76.8% of the healthy weight group (P = .03). Differences between BMI groups in the proportion reaching Minimal Clinically Important Difference at 1 year were not significant.

CONCLUSIONS

Patients of higher BMI reported greater and earlier improvements in satisfaction, knee function, and pain following TKA. Shared decision-making remains paramount to preoperative surgical evaluation. However, rationing of this surgical intervention based on BMI alone may not be warranted.

Responsiveness of the PROMIS physical function measure in orthopaedic trauma patients

OBJECTIVES

To compare the responsiveness of the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) to the 36-Item Short Form Survey Physical Component Score (SF36-PCS) in orthopaedic trauma patients from pre-injury to one year recovery.

DESIGN AND SETTING

Prospective cohort study at a Level 1 trauma centre.

PARTICIPANTS

Patients over the age of 18 with orthopaedic trauma injuries to the pelvis, lower extremity or upper extremity between 2017 and 2018.

MAIN OUTCOMES MEASUREMENTS

The PROMIS-PF and SF36-PCS assessments were conducted at baseline, 3 months, 6 months and 12 months. Responsiveness of each measure was assessed between time points by calculating the standardized response mean (SRM), the proportions of patients exceeding minimal clinically important difference (MCID), and the floor and ceiling effects.

RESULTS

Sixty-eight patients with completed assessments at every timepoint were included: mean age 44.7 years, 39 were male and mean Injury Severity Score (ISS) was 7.4 (range: 4-16). Mean time of completion for the SF-36 at all the time points was 5.6 min vs 1.7 min for the PROMIS-PF (p<0.01). The SRM was comparable between measures at all the time points. Although a greater proportion of patients achieved MCID for SF36-PCS between all the time points, this only approached statistical significance between the 6- and 12-month assessments (47.1% vs 33.8%; p = 0.15). There was a significant ceiling effect demonstrated with the PROMIS-PF at baseline and 12-month assessments, with 34 (50.0%) patients and 7 (10.3%) patients achieving the maximum scores at each time point, respectively.

DISCUSSION AND CONCLUSIONS

PROMIS-PF has a more favourable responder burden based on lower time to completion and comparable responsiveness to the SF-36 PCS. However, there are limitations in responsiveness with the PROMIS-PF in patients who are higher functioning as demonstrated by the ceiling effects in patients at baseline pre-injury and at 12 months post-injury timepoints.

Toward a rigorous assessment of the statistical performances of methods to estimate the Minimal Important Difference of Patient-Reported Outcomes: a protocol for a large-scale simulation study

Interpreting observed changes over time in Patient-Reported Outcomes (PRO) measures is still considered a challenge. Indeed, concluding an observed change at group level is statistically significant does not necessarily equate this change is meaningful from the perspective of the patient. To help interpret within and/or between group changes in the measure over time, the estimation of the Minimal Important Difference (MID) of the instrument - the smallest value that patients consider as a perceived change - is useful. In the last 30 years, a plethora of methods and estimators have been proposed to derive this MID value using clinical data from sample of patients. MIDs for hundreds of PROs have been estimated, with frequently a substantial variability in the results depending on the method used. Nonetheless, a rigorous assessment of the statistical performances of numerous proposed methods for estimating MIDs by experimental design such as Monte-Carlo study has never been performed. The purpose of this paper is to thoroughly depict a protocol for a large-scale simulation study designed to investigate the statistical performances, especially bias against a true populational value, of the common proposed estimators for MID. This paper depicts how investigated methods and estimators were retained after the conduct of a systematic review, the design of a conceptual model that formally defines what is the true populational MID value and the translation of the conceptual model into a model allowing the simulation of responses of items to a hypothetical PRO at two times of measurement along with the response to a Patient Global Rating of Change at the second time under the constraint of a known true MID value. A statistical analysis plan is depicted in order to conclude if working hypotheses on what could be appropriate MID estimators will be verified. Strengths, assumptions, and limits of the simulation model are exposed. Finally, we show how this protocol could be the basis for fostering future methodological research on the issue of interpreting changes in PRO measures.

Responsiveness and Minimal Clinically Important Difference of the Brief-BESTest in People With COPD After Pulmonary Rehabilitation

OBJECTIVE

he Brief-Balance Evaluation Systems Test (Brief-BESTest) is a comprehensive, reliable, and valid balance test that provides valuable information to guide balance training in people with chronic obstructive pulmonary disease (COPD). Its clinical interpretability is, however, currently limited, because cutoff points to identify clinically relevant changes in people with COPD after pulmonary rehabilitation are still lacking. This study aimed to establish the responsiveness and minimal clinically important difference (MCID) for the Brief-BESTest in people with COPD after pulmonary rehabilitation (PR).

METHODS

A secondary analysis of data from 2 previous studies was conducted. The modified British Medical Research Council (mMRC) dyspnea scale, the 6-Minute Walk Test (6-MWT), and the Brief-BESTest (0-24 points) were collected in people with COPD pre/post a 12-week PR program including balance training. The MCID was computed using anchor- and distribution-based methods. Changes in the 6-MWT and the mMRC were assessed and used as anchors. The pooled MCID was computed using the arithmetic weighted mean (2/3 anchor- and 1/3 distribution-based methods).

RESULTS

Seventy-one people with COPD (69 years [SD = 8]; 76% male; FEV1 = 49.8%predicted [SD = 18%]) were included. There was a significant improvement in the Brief-BESTest after PR (mean difference = 3 points [SD = 3]). Significant correlations were found between the Brief-BESTest and the mMRC (r = -.31) and the 6-MWT (r = .37). The pooled MCID was 3.3 points.

CONCLUSION

An improvement of at least 3 points in the Brief-BESTest in people with COPD will enhance the interpretability of PR effects on balance performance of this population and guide tailored interventions.

IMPACT

The Brief-BESTest outcome measure is comprehensive, easily administered, and simple to interpret in clinical practice. This study represents a significant contribution toward the clinical interpretation of changes in balance in people with COPD following PR.

Effective dose 50 method as the minimal clinically important difference: Evidence from depression trials

OBJECTIVE

Previous research on the minimal clinically important difference (MCID) for depression and anxiety is based on population averages. The present study aimed to identify the MCID across the spectrum of baseline severity.

STUDY DESIGN AND SETTINGS

The present analysis used secondary data from 2 randomized controlled trials for depression (n = 1,122) to calibrate the Global Rating of Change with the PHQ-9 and GAD-7. The MCID was defined as a change in scores corresponding to a 50% probability of patients "feeling better", given their baseline severity, referred to as Effective Dose 50 (ED50).

RESULTS

MCID estimates depended on baseline severity and ranged from no change for very mild up to 14 points (52%) on the PHQ-9 and up to 10 points (48%) on the GAD-7 for very high severity. The average MCID estimates were 3.7 points (23%) and 3.3 (28%) for the PHQ-9 and GAD-7 respectively.

CONCLUSION

The ED50 method generates MCID estimates across the spectrum of baseline severity, offering greater precision but at the cost of greater complexity relative to population average estimates. This has important implications for evaluations of treatments and clinical practice where users can use these results to tailor the MCID to specific populations according to baseline severities.

The minimal perceived change: a formal model of the responder definition according to the patient's meaning of change for patient-reported outcome data analysis and interpretation

Background

Patient-Reported Outcomes (PROs) are standardized questionnaires used to measure subjective outcomes such as quality of life in healthcare. They are considered paramount to assess the results of therapeutic interventions. However, because their calibration is relative to internal standards in people’s mind, changes in PRO scores are difficult to interpret.

Knowing the smallest value in the score that the patient perceives as change can help. An estimator linking the answers to a Patient Global Rating of Change (PGRC: a question measuring the overall feeling of change) with change in PRO scores is frequently used to obtain this value. In the last 30 years, a plethora of methods have been used to obtain these estimates, but there is no consensus on the appropriate method and no formal definition of this value.

Methods

We propose a model to explain changes in PRO scores and PGRC answers.

Results

A PGRC measures a construct called the Perceived Change (PC), whose determinants are elicited. Answering a PGRC requires discretizing a continuous PC into a category using threshold values that are random variables. Therefore, the populational value of the Minimal Perceived Change (MPC) is the location parameter value of the threshold on the PC continuum defining the switch from the absence of change to change.

Conclusions

We show how this model can help to hypothesize what are the appropriate methods to estimate the MPC and its potential to be a rigorous theoretical basis for future work on the interpretation of change in PRO scores.

Minimal Clinically Important Difference (MCID) for the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire - IUGA Revised (PISQ-IR)

BACKGROUND

To put statistically significant changes in patient reported outcome measurement (PROM) questionnaires into a clinical perspective, the concept of the minimal clinically important difference (MCID) can be used.

AIM

To determine the MCID for the summary score for sexually active (SA) women of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR), a validated instrument which assesses sexual functioning (SF) for patients suffering from a symptomatic pelvic floor disorder.

METHODS

Patients participating in a multicentre prospective cohort study comparing pessary therapy with surgery for a symptomatic pelvic organ prolapse (POP) filled in the PISQ-IR at baseline and 12 months' follow-up. We used both an anchor-based as well as a distribution-based method to calculate the MCID for both treatment groups. The Patient Global Impression of Improvement (PGI-I) questionnaire and PISQ-IR question 19a about satisfaction with sexual functioning were used as anchors. For the distribution-based approach we used the effect size (ES).

OUTCOMES

MCID for the SA summary score of the PISQ-IR.

RESULTS

Data of 243 women were used to calculate the MCID. In the pessary group, Kendall's tau-b correlation coefficients between the PISQ-IR summary score and both anchors were below the cut-off of 0.21, which implies the anchors cannot be used to calculate an MCID. In our surgery group, the PISQ-IR question 19a met the anchor criteria and 0.31 points increase in the PISQ-IR summary score was equal to an improvement of 1 point on question 19a about satisfaction with sexual functioning.

CLINICAL IMPLICATIONS

Future research on this subject should focus on clinical relevance of results rather than statistical significance only.

STRENGTHS & LIMITATIONS

Our main strength is the fact that we used both anchor-based and distribution-based methods to determine our MCID. Secondly, we set out to determine an MCID for both treatment groups separately, which relatively enhances the generalisability of our results. A limitation is that we were not able to estimate an MCID for the pessary group. Pruijssers B, van der Vaart L, Milani F, et al. Minimal Clinically Important Difference (MCID) for the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire - IUGA Revised (PISQ-IR). J Sex Med 2021;18:1265-1270.

CONCLUSION

We estimated the MCID for the PISQ-IR SA summary score to be 0.31 in our surgery group.

Functional capacity assessment and Minimal Clinically Important Difference in post-acute cardiac patients: the role of Short Physical Performance Battery

BACKGROUND

The Short Physical Performance Battery (SPPB) test is a well-established tool to assess physical performance, and to identify frail patients. Assessment of the SPPB in a specific population of elder patients in cardiac rehabilitation phase after a cardiac event is missing.

AIM

The aim of this study was to correlate SPPB and the cardiac rehabilitation outcome in a group of elder patients after a cardiac event and to identify the Minimal Clinically Important Difference (MCID) of the SPPB.

METHODS

Consecutive (n = 392) patients aged ≥75 years, in the rehabilitation phase after cardiac surgery (70.1%), congestive heart failure (7.4%), or acute coronary syndrome (22.5%), were enrolled. SPPB was performed twice: on admission and discharge. The MCID was assessed with the 'anchor method', and the Patient Global Impression of Change was employed as the anchor.

RESULTS

On admission, SPPB classified 56, 117, 116, and 94 patients as severe, moderate, mild, or minimal/no limitations, respectively. Patients with the lower SPPB had the longer length of stay, and the higher complications rate. At receiver operating characteristic analysis, an SPPB improvement >1 was identified as the MCID (area-under-curve 0.77, 95% CI 0.67-0.85). Overall, 285 patients (74.2%) had a 'clinically significant' improvement in SPPB, with a rate of improvement higher in patients with severe/moderate limitations (83.0%) and lower in those with mild (78.9%) or minimal/no limitations (53.6%).

CONCLUSION

A lower SPPB score is associated with a higher complications rate in the post-acute phase. An improvement >1 point of SPPB was identified as the MCID; this reference value could serve as the goal for rehabilitation interventions.

Minimal Clinically Important Differences for Measures of Pain, Lung Function, Fatigue, and Functionality in Spinal Cord Injury

OBJECTIVE

The objective of this study was to determine the minimal clinically important differences (MCIDs) for the numerical pain rating scale (NPRS), peak cough flow (PCF), peak expiratory flow (PEF), fatigue severity scale (FSS), and London chest activities of daily living scale (LCADL) in patients with spinal cord injuries (SCIs) after rehabilitation.

METHODS

Inpatients with SCI from 2 rehabilitation centers participating in a daily rehabilitation program were recruited. The NPRS, PCF, PEF, FSS, and LCADL were collected at baseline and discharge. The global rating of change scale was performed at discharge. MCIDs were calculated using anchor (linear regression, mean change, and receiver operating characteristic curves) and distribution-based methods (0.5 times the baseline SD, standard error of measurement, 1.96 times standard error of measurement, and minimal detectable change) and pooled using arithmetic weighted mean.

RESULTS

Sixty inpatients with SCI (36 males; 54.5 [15.9] years) participated. On average their rehabilitation program lasted 7.3 (1.7) weeks. Pooled MCID estimates were 1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL.

CONCLUSION

Established MCIDs for NPRS, PCF, PEF, FSS, and LCADL will help health professionals to interpret results and guide rehabilitation interventions in patients with SCI.

IMPACT

Health professionals and researchers may now use -1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL to interpret if changes in pain, cough intensity, expiratory flow, fatigue and activities of daily living after rehabilitation of patients with SCI have been clinically relevant.

IMPROVEMENTS IN HIP OSTEOARTHRITIS WITH LAVAGE, TRIAMCINOLONE AND HYLAN G-F20

Objective:

To verify whether the use of Hylan G-F20 improves saline lavage and triamcinolone injection results in the treatment of hip osteoarthritis (HOA).

Methods:

82 patients with HOA categorized as grades II and III severity, according to Kellgren and Lawrence criteria, were randomized into the groups: lavage and triamcinolone (G0); lavage, triamcinolone, and 2 mL of hylan G-F20 (G1); lavage, triamcinolone, and 4mL of hylan G-F20 (G2); lavage, triamcinolone, and 6mL of hylan G-F20 (G3). The VAS, range of motion (ROM), WOMAC, and Lequesne questionnaires were administered at baseline, one, three, six, and twelve months post-injection.

Results:

All groups showed clinically relevant improvements (> 20%) between baseline and first month post-injection, maintaining subjective results throughout the study period (p < 0.001). We found no differences between groups in any subjective evaluations (p > 0.05, for all). G2 and G3 obtained improved flexion results up to a year (p = 0.028). Hylan groups presented an improved external rotation since the first postoperative month and maintained the results up to a year (G1, p = 0.041; G2, p = 0.007), whereas G0 showed no improvement (p = 0.336).

Conclusion:

Hip lavage and triamcinolone injection, with or without the use of hylan, improves pain, function, and quality of life up to a year in HOA. Hylan may improve ROM up to one year. Level of Evidence IB, Randomized clinical trial.

Do older adults with shoulder disorders who meet the minimal clinically important difference also present low disability at discharge? An observational study

BACKGROUND

The choice of outcome success thresholds may influence clinical management, pay-for-performance, and assessment of value-based care.

OBJECTIVE

To evaluate outcomes success thresholds in older adults using two different methods: 1) Minimal clinically important differences (MCIDs) of the Quick-DASH and 2) Dichotomization of the Quick-DASH based on low disability rating at discharge DESIGN: An observational design (retrospective database study).

SETTING

Dataset of 1109 patients with shoulder disorders.

PARTICIPANTS

297 older adults patients who were diagnosed with rotator cuff related shoulder disorders and were managed through physical therapy treatment.

MAIN OUTCOME MEASURES

We categorized and calculated how many patients met 8.0 and 16.0 point changes on the Quick-DASH. To evaluate outcomes success thresholds using dichotomization, patients who discharge score of ≤20 on the Quick-DASH were considered positive responders with successful outcomes.

RESULTS

The percentage of positive responders who met the MCID thresholds for the Quick-DASH were 63.3% using MCID of 8.0 points, 39.7% using the MCID of 16.0 points, and 46.12% who met discharge score of ≤ 20 on the Quick-DASH. 39.0% met both MCID of 8.0 points and discharge score of ≤ 20 on the Quick-DASH. Only 28% met both MCID of 16.0 points and discharge score of = 20 on the Quick-DASH.

CONCLUSION

Three different success threshold derivations classified patients into three very different assessments of success. Quick-DASH scores of ≤ 20 represent low levels of self-report disability at discharge and can be a stable clinical option for a measure of success to capture whether a treatment results in meaningful improvement.

Minimal Important Difference in Outcome of Disc Degenerative Disease Treatment: The Patients' Perspective

Evaluation of treatments effectiveness in a context of value-based health care is based on outcomes, and in their assessment. The patient perspective is gaining renovated interest, as demonstrated by the increasing diffusion of Patient Reported Outcome Measure (PROMs) collection initiatives. The concept of Minimal Clinically Important Dif-ference (MID) is generally seen as the basis to estimate the actual effect perceived by the patient after a treatment, like a surgical intervention, but a universally recognized threshold has not yet been established. At the Orthopedic Institute Galeazzi (Milan, Italy) we began a digitized program of PROM collection in spine surgery by means of a digital platform, called Datareg. In this work we aim to investigate MID in the treatment of degenerated disc in terms of patients' perceptions as these are collected through the above electronic registry. We proposed a computation of MID on the basis of two PROM scores, and a critical comparison with a domain expert's proposal.

Report of the Primary Outcomes for Gait Mechanics in Men of the ACL-SPORTS Trial: Secondary Prevention With and Without Perturbation Training Does Not Restore Gait Symmetry in Men 1 or 2 Years After ACL Reconstruction

BACKGROUND

Movement asymmetries during walking are common after anterior cruciate ligament (ACL) injury and reconstruction and may influence the early development of posttraumatic osteoarthritis. Preoperative neuromuscular training (like perturbation training, which is neuromuscular training requiring selective muscle activation in response to surface perturbations) improves gait asymmetries and functional outcomes among people who are ACL-deficient, but the effect of postoperative perturbation training on gait mechanics after ACL reconstruction is unknown.

QUESTIONS/PURPOSES

Among men undergoing ACL reconstruction, we sought to compare strength, agility, and secondary prevention (SAP) treatment with SAP plus perturbation training (SAP+PERT) with respect to (1) gait mechanics; and (2) elimination of gait asymmetries 1 and 2 years after ACL reconstruction.

METHODS

Forty men were randomized into a SAP group or a SAP+PERT group after ACL reconstruction and before returning to preinjury activities. Participants were required to achieve ≥ 80% quadriceps muscle strength symmetry, minimal knee effusion, full ROM, no reports of pain, and completion of a running progression (all between 3 and 9 months postoperatively) before enrollment. Of 94 potentially eligible athletic male patients evaluated < 9 months after ACL reconstruction, 54 were excluded for prespecified reasons. Participants underwent motion analysis during overground walking at 1 and 2 years postoperatively. Variables of interest included (1) sagittal and frontal plane hip and knee angles and moments at peak knee flexion angle; (2) sagittal plane hip and knee angles and moments at peak knee extension angle; (3) sagittal plane hip and knee excursion during weight acceptance; and (4) sagittal plane hip and knee excursion during midstance. We also calculated the proportion of athletes in each group who walked with clinically meaningful interlimb asymmetry in sagittal plane hip and knee variables and compared these proportions using odds ratios. There was no differential loss to followup between groups.

RESULTS

There were no differences between the SAP or SAP+PERT groups for the biomechanical gait variables. The involved limb's knee excursion during midstance for the SAP (mean ± SD: 1 year: 15° ± 5°; 2 years: 16° ± 5°) and SAP+PERT (1 year: 16° ± 5°; 2 years: 15° ± 4°) athletes was not different between groups at 1 year (mean difference: -1°; 95% confidence interval [CI], -5° to 2°; p = 0.49) or 2 years (mean difference: 1°; 95% CI, -2° to 4°; p = 0.54). There were no differences between SAP and SAP+PERT athletes regarding the elimination of gait asymmetries, and gait asymmetries persisted to a large degree in both groups 1 and 2 years postoperatively. At 1 year, 11 of 18 SAP and 11 of 20 SAP+PERT athletes walked with truncated knee excursions during weight acceptance (odds ratio: 0.8, p = 0.70) and midstance (SAP 12 of 18, SAP+PERT 12 of 20; odds ratio: 0.8, p = 0.67), whereas at 2 years postoperatively, truncated knee excursions during weight acceptance (SAP seven of 17, SAP+PERT eight of 19; odds ratio: 1.0, p = 0.96) and midstance (SAP five of 17, SAP+PERT 11 of 19; odds ratio: 3.3, p = 0.09) remained prevalent.

CONCLUSIONS

We found that a comprehensive, progressive return-to-sport training program with or without perturbation was not effective at restoring interlimb symmetry among men 1 or 2 years after ACL reconstruction. Although gait asymmetries improved from 1 to 2 years postoperatively, meaningful asymmetries persisted in both groups. To restore gait symmetry after ACL reconstruction, additional interventions likely are necessary.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Assessing Pruritus in Hidradenitis Suppurativa: A Cross-Sectional Study

BACKGROUND

Pruritus is still a forgotten aspect of hidradenitis suppurativa (HS) and, to date, has never been adequately studied.

OBJECTIVE

The aim of this study was to determine the prevalence, and explore the characteristics, of pruritus in a well-defined cohort of HS patients.

SETTING

An academic hospital-based cross-sectional study in The Netherlands.

METHODS

A numerical rating scale (NRS, 0-10) was used to determine the prevalence of HS-related itch (NRS score ≥3). Candidate predictors for pruritus were subsequently determined using logistic regression models, and the impact of pruritus was assessed using a modified five-dimensional (5-D) itch scale. Associated serological and histological markers of pruritus were (semi-)quantitatively investigated in a subpopulation.

RESULTS

The prevalence rate of pruritus in 211 HS patients was 57.3%, with a mean NRS score of 6.1 ± 2.0. Patients with a pruritus NRS score ≥3 had more HS-affected body sites than patients with a score <3 (p < 0.001). The occurrence of a pruritus NRS score ≥3 was associated with Hurley III disease (odds ratio [OR] 7.73; p = 0.003) and pain (OR 1.34; p < 0.001). Pruritus affected sleep and activities of daily living (ADL) in the majority of cases, with an associated modified 5-D itch score of 13.7 ± 3.6 (on a scale from 5 to 25) in 52 HS patients. Histological examination showed eosinophilic granulocytes were present in 25% (2/8) of the perilesional skin and 63% (10/16) of the lesional skin, while a perineural infiltrate was found in 25% (2/8) and 69% (11/16) of the perilesional and lesional skin, respectively.

CONCLUSION

Pruritus is a frequent but underreported symptom in patients with HS. Its moderate to severe intensity and significant impact on daily activities have great potential to impair patients' quality of life.

Defining the minimal clinically important difference (MCID) of the Heinrichs-carpenter quality of life scale (QLS)

To determine the Minimal Clinically Important Difference (MCID) of the Heinrichs-Carpenter Quality of Life Scale (QLS). Data from the "Schizophrenia Trial of Aripiprazole" (STAR) study were used in this analysis. The MCID value of the QLS total score was estimated using the anchor-based method. These findings were substantiated/validated by comparing the MCID estimate to other measurements collected in the study. Half of the patients (49%) showed improvement in Clinical Global Impressions of Severity (CGI-S) during the trial. The estimated MCID of the QLS total score was 5.30 (standard error: 2.60; 95% confidence interval: [0.16; 10.43]; p < 0.05). Patients were divided into two groups: "QLS improvers" (QLS total score increased ≥ six points) and "non-improvers". The QLS improvers had significantly better effectiveness and reported significantly higher levels of preference for their current medications. There was a statistically significant difference between the two groups in the change in two of the four domains of QLS; "Interpersonal relations" and "Intrapsychic foundations" domains during the study. These findings support the value of the estimated MCID for the QLS and may be a useful tool in evaluating antipsychotic treatment effects and improving long-term patient outcomes in schizophrenia. Copyright © 2015 John Wiley & Sons, Ltd.

At Completion of a Multidisciplinary Treatment Program, Are Psychophysical Variables Associated with a VAS Improvement of 30% or More, a Minimal Clinically Important Difference, or an Absolute VAS Score Improvement of 1.5 cm or More?

OBJECTIVES

Objectives were to determine at completion of a multidisciplinary pain program: 1) what percentage of chronic low back pain (CLBP) patients had improved at 30% or more (minimal clinically important difference [MCID]) and by 1.5 cm or more (minimal important change [MIC]) on the visual analog scale (VAS) and 2) whether that improvement is associated with pain matching (PM), pain threshold (PTRE), and pain tolerance (PTOL) improvements.

METHODS

One hundred and six CLBP patients had admission and discharge scores for VAS, PM, PTRE, and PTOL. Improvement was determined by absolute, MCID, and MIC VAS improvement. Logistic regression analysis controlling for age, gender, race, education, psychoactive substance dependence, and depression was utilized to develop models for the dependent variables of improvement of overall VAS; of MCID of 50% or more; and of MIC with PM, PTOL, and PTRE as independent variables.

RESULTS

Thirty-two percent and 35% of the CLBP patients were at MCID and MIC, respectively, at discharge (68% and 65% not at MCID and MIC, respectively), and 54.7% were improved overall. Of the improved patients, 59% were at MCID and 63.7% at MIC. PM was associated with overall VAS improvement, while PTRE and PM were associated with MCID improvement. MIC and 50% or above models could not be estimated.

LIMITATIONS

The VAS was treated as a ratio scale.

CONCLUSIONS

A significant percentage of CLBP patients were at MCID and at MIC at completion of multidisciplinary treatment. PM was associated with overall VAS improvement, while PTRE and PM were associated with MCID.

Nonresponders, partial responders, and complete responders to PDE5 inhibitors therapy according to IIEF criteria: validation of an anchor-based treatment responder classification

INTRODUCTION

Despite widespread use of the International Index of Erectile Function (IIEF) in erectile dysfunction (ED) research, there are no published criteria for classifying ED treatment responders in clinical trials or patient management settings. A new classification for treatment response in men with ED has been developed and validated in a large clinical trial database.

AIM

The study aims to test discriminant and convergent validity of the responder classification and examine the role of covariates.

METHOD

Treatment assignment was used to test discriminant validity. The diary-based Sexual Encounter Profile (SEP) question ("Did your erection last long enough for you to have successful intercourse?") and Global Assessment Question (GAQ) ("Has the treatment you have been taking over the past study interval improved your erections?") were used to evaluate convergent validity. Chi-square and Cochran-Armitage trend tests were used to examine outcome associations. Logistic regression was used to further assess the relationship of outcomes controlling for covariates.

MAIN OUTCOME MEASURE

The classification measure was developed and validated in a database from 17 clinical trials in 3,252 men with ED randomized to placebo or tadalafil. The treatment responder is defined as complete (erectile function [EF] ≥ 26); partial (EF < 26; met minimal clinically important difference [MCID] criteria); or nonresponder following treatment (EF < 26; did not meet MCID).

RESULTS

The new responder definition performed consistently well in all prespecified tests of validity. Eighty-nine percent of subjects classified as complete responders were in the treatment group, and the responder definition was associated with changes on the SEP and GAQ measures, respectively (SEP odds ratio [OR] = 14, 95% confidence intervals [CI] 11-17; GAQ OR = 50, 95% CI 39-88; complete vs. nonresponders).

CONCLUSIONS

We developed and validated a novel method of defining an ED treatment responder based on multiple IIEF criteria and using other measures (SEP, GAQ) for validation. The results have implications for understanding results of clinical trials in ED, and in monitoring response to treatment in the clinic.