Exploring factors influencing low back pain in people with non-dysvascular lower limb amputation: a national survey

Background: Chronic low back pain (LBP) is a common musculoskeletal impairment in people with lower limb amputation. Given the multifactorial nature of LBP, exploring the factors influencing the presence and intensity of LBP is warranted. Objective: To investigate which physical, personal, and amputee-specific factors predicted presence and intensity of low back pain (LBP) in persons with non-dysvascular transfemoral (TFA) and transtibial amputation (TTA). Design: A retrospective cross-sectional survey. Setting: A national random sample of people with non-dysvascular TFA and TTA. Participants: Participants (N = 526) with unilateral TFA and TTA due to non-dysvascular aetiology (i.e. trauma, tumours, and congenital causes) and a minimum prosthesis usage of one year since amputation were invited to participate in the survey. The data from 208 participants (43.4% response rate) were used for multivariate regression analysis Methods (Independent variables): Personal (i.e. age, body mass, gender, work status, and presence of comorbid conditions), amputee-specific (i.e. level of amputation, years of prosthesis use, presence of phantom limb pain, residual limb problems, and non-amputated limb pain), and physical factors (i.e. pain provoking postures including standing, bending, lifting, walking,sitting, sit-to stand, and climbing stairs). Main outcome measures (Dependent variables): LBP presence and intensity. Results: A multivariate logistic regression model showed that the presence of two or more comorbid conditions (prevalence odds ratio (POR) = 4.34, p = .01), residual limb problems (POR 22 = 3.76, p<.01), and phantom limb pain (POR = 2.46, p = .01) influenced the presence of LBP. Given the high LBP prevalence (63%) in the study, there is a tendency for overestimation of PORand the results must be interpreted with caution. In those with LBP, the presence of residual limb problems (beta = 0.21, p = .01), and experiencing LBP symptoms during sit-to-stand task (beta = 0.22, p = .03) were positively associated with LBP intensity, while being employed demonstrated a negative association (beta = - 0.18, p = .03) in the multivariate linear regression model. Conclusions: Rehabilitation professionals should be cognisant of the influence that comorbid conditions, residual limb problems, and phantom pain have on the presence of LBP in people with non-dysvascular lower limb amputation. Further prospective studies could investigate the underlying causal mechanisms of LBP

Development and content validity of the Musculoskeletal Self-Management Questionnaire (MSK-SMQ)

Background Self-management is recommended for managing persistent musculoskeletal conditions. In self-management, standardized and validated measurements (e.g., questionnaires) should be used. However, there is no general questionnaire to evaluate the level of self-management in people with persistent musculoskeletal conditions. Objectives To develop a generic questionnaire to evaluate the level of self-management and self-management skills in people with persistent musculoskeletal conditions. Design Measurement properties study focused on the development and content validity of the Musculoskeletal Self-Management Questionnaire (MSK-SMQ). Methods The MSK-SMQ was developed, consisting of 24 questions. To assess the content validity of the MSK-SMQ, three panels (patients, professionals, researchers/academics) were used. The relevance, clarity and essentiality of each question was evaluated. Moreover, specific feedback could be provided. The Content Validity Index (CVI) was used to test content validity (Item-CV [I-CVI]) and the Scale-level-CVI [S-CVI]). The CVI was calculated for both relevance and clarity. The essentiality of each item was measured with the content validity ratio (CVR). Results/findings 91 people participated in this study. The overall content validity (relevance) was excellent, with an S-CVI of 0.96. Overall clarity was also excellent, with a score of 0.97. The range of the I-CVI for relevance was 0.91 – 1.00 and the range for clarity was 0.93 – 1.00. The mean CVR value was 0.51 and ranged from 0.14 to 0.87. Conclusions The content validity of the questionnaire was found to be excellent. The study resulted in a revised version of the MSK-SMQ, which can be used in future research to determine further psychometric properties

Exploring low back pain and spinal movement asymmetries in people with non-dysvascular lower limb amputation

Background and aim Low back pain (LBP) is a major secondary impairment following lower limb amputation including those with transfemoral (TFA) and transtibial amputation (TTA). The two main aims of this thesis were to explore, (1) the LBP prevalence, nature, and perceptions of LBP and (2) asymmetrical movements of the spinal and pelvic segments during common functional tasks in people with TFA and TTA due to non-dysvascular aetiology (i.e. trauma and tumours). Methods This thesis comprised four studies that addressed the overall aims of thesis. A systematic review (Study 1) of literature was undertaken to investigate the spinal and pelvic movement asymmetries during functional tasks in people with lower limb amputation. A focus group study (Study 2) explored the LBP perceptions and common functional activities related to LBP in people with lower limb amputation and ongoing LBP. Reflections on common daily activities increasing LBP symptoms informed the development of functional activity questions for the national survey study (Study 3). The survey study then investigated the LBP prevalence and identified functional activities and postures which often aggravate LBP symptoms in people with lower limb amputation in New Zealand. Results from survey and focus group studies informed the functional tasks (i.e. walking, lifting, and sit-to-stand) for further biomechanical analysis in the motion analysis study (Study 4). A cross-sectional biomechanical laboratory study was conducted to explore the differences in three-dimensional spinal and pelvic kinematics during three common functional tasks (i.e. walking, lifting, and sit-to-stand) in people with TFA and TTA, with and without LBP. Results The systematic review found no previous study specifically investigating spinal and pelvic movement asymmetries during functional tasks other than walking (e.g. stair climbing, ramp walking, and obstacle crossing) in people with TFA and TTA. The results from the focus group study suggest participants with ongoing LBP believe ‘uneven movements of the back’ during functional tasks to be a main contributing factor to their symptoms. Uneven movements during functional tasks were perceived to be affected by ‘fatigue’ and ‘prosthesis-related factors’, such as limb-length discrepancy, prosthetic fit, and type of prosthesis. Participants felt ‘being physically active’ and improved physical fitness levels following amputation may be beneficial to minimise uneven movements and LBP. From the results of the national survey, LBP is highly prevalent, affecting up to 67% of people with TFA and TTA and appears to be both chronic and intermittent in nature. Non-mechanical factors such as phantom limb pain, residual limb problems, and the presence of comorbid health conditions (e.g. heart disease, diabetes, and depression) increase the risk of developing LBP up to 30 times in people with TFA and TTA. Standing (88.5%), adopting a bent posture (80%), walking (77.5%), and sitting (72%) were reported as common pain provoking activities and postures in people with TFA and TTA. The biomechanical laboratory study identified preliminary evidence for the presence of differences in spinal and pelvic movements of people with TFA-LBP and TFA-No LBP during walking. There were no differences in the spinal and pelvic kinematics of people with TTA-LBP and TTA-No LBP during walking, lifting, and sit-to-stand tasks. Conclusion Low back pain is a highly prevalent yet overlooked chronic pain condition in people with lower limb amputation due to non-dysvascular aetiology. The nature of LBP appears to be chronic and intermittent with ‘uneven movements of the back’ perceived as a main contributor to LBP. The results from the biomechanical laboratory study highlight the potentially important kinematic differences between the LBP and no LBP groups in persons with TFA during walking. They provide a background for future hypothesis-based studies investigating the potential causal links between the identified spinal and pelvic asymmetries and LBP as well as to devise prevention and treatment strategies for LBP in this population. Clinicians involved in treating LBP in people with lower limb amputation may have to be cognisant about the multifactorial nature of LBP and the potential for other pain conditions (i.e. phantom limb and residual limb pain) influencing the chronicity of LBP symptoms. Furthermore, individuals with a lower limb amputation need to be educated about the underlying biomechanical issues associated with common functional tasks in order to minimise the risk of developing musculoskeletal impairments such as LBP

Current evidence for nonpharmacological interventions and criteria for surgical management of persistent acromioclavicular joint osteoarthritis: A systematic review

BackgroundThe primary aim of this systematic review was to investigate the individual/combined effectiveness of nonpharmacological interventions in individuals with persistent acromioclavicular joint osteoarthritis. The secondary aims were to investigate the comparative effectiveness of nonpharmacological versus surgical interventions, and to identify the criteria used for defining failure of conservative interventions in individuals who require surgery for persistent acromioclavicular joint osteoarthritis.MethodMajor electronic databases were searched from inception until October 2018. Studies involving adults aged 16 years and older, diagnosed clinically and radiologically with isolated acromioclavicular joint osteoarthritis for at least three months or more were included. Studies must explicitly state the type and duration of conservative interventions. Methodological risk of bias was assessed using the Modified Downs and Black checklist.ResultsTen surgical intervention studies were included for final synthesis. No studies investigated the effectiveness of nonpharmacological interventions or compared them with surgical interventions. Common nonpharmacological interventions trialed from the 10 included studies were activity modification (n = 8) and physiotherapy (n = 4). Four to six months was the most often reported timeframe defining failure of conservative management (range 3–12 months).ConclusionsCurrently, there is no evidence to guide clinicians about the individual or combined effectiveness of nonpharmacological interventions for individuals with persistent acromioclavicular joint osteoarthritis.</jats:sec

“A coalition of the willing”: experiences of co-designing an online pain management programme (iSelf-help) for people with persistent pain

Abstract Background Participatory approaches to developing health interventions with end-users are recommended to improve uptake and use. We aimed to explore the experiences of co-designing an online-delivered pain management programme (iSelf-help) for people with persistent pain. Methods A modified participatory action research (PAR) framework was used to co-design contents and delivery of iSelf-help. The PAR team included: (1) a patient advisory group consisting of people living with persistent pain (n = 8), (2) pain management service clinicians (n = 2), (3) health researchers (n = 3), (4) digital health experts (n = 2), (5) a health literacy expert, and (6) two Māori health researchers and our community partner who led the cultural appropriateness of iSelf-help for Māori (the Indigenous population of New Zealand). The iSelf-help co-design processes and activities of the ‘PAR’ team is reported in another paper. In this paper, all PAR team members were invited to share their experiences of the co-design process. Individual interviews were held with 12 PAR team members. Interview transcripts were analysed using the General Inductive Approach. Results Five common themes were identified from the interviews: (1) Shared understanding and values of the co-design process, (2) Mismatched expectations with content creation, (3) Flexibility to share power and decision making, (4) Common thread of knowledge, and (5) Shared determination. Sustaining these themes was an overarching theme of “A coalition of the willing”. Conclusions PAR team members valued the shared determination and responsibility to co-design iSelf-help. They also acknowledged the complexities and challenges during the process related to mismatched expectations, power sharing and establishing a common thread of knowledge. Successful co-design requires a shared commitment and responsibility as a coalition to meet the aspirations of end-users, within the boundaries of time and budget. </jats:sec