Predicting outcome in acute low back pain using different models of patient profiling

Study Design: Prospective observational study of prognostic indicators, utilising data from a randomised, controlled trial of physiotherapy care of acute low back pain (ALBP) with follow up at 6 weeks, 3 months and 6 months. Objective: To evaluate which patient profile offers the most useful guide to long-term outcome in ALBP. Summary of Background Data: The evidence used to inform prognostic decision-making is derived largely from studies where baseline data is used to predict future status. Clinicians often see patients on multiple occasions so may profile patients in a variety of ways. It is worth considering if better prognostic decisions can be made from alternative profiles. Methods: Clinical, psychological and demographic data were collected from a sample of 54 ALBP patients. Three clinical profiles were developed from information collected at baseline, information collected at 6 weeks, and the change in status between these two time points. A series of regression models were used to determine the independent and relative contributions of these profiles to the prediction of chronic pain and disability. Results: The baseline profile predicted long-term pain only. The 6-week profile predicted both long-term pain and disability. The change profile only predicted long-term disability (p \u3c 0.01). When predicting long-term pain, after the baseline profile had been added to the model, the 6-week profile did not add significantly when forced in at the second step (p \u3e 0.05). A similar result was obtained when the order of entry was reversed. When predicting long-term disability, after the 6-week profile was entered at the first step, the change profile was not significant when forced in at the second step. However, when the change profile was entered at the first step and the 6-week clinical profile was forced in at the second step, a significant contribution of the 6-week profile was found. Conclusions: The profile derived from information collected at 6 weeks provided the best guide to long-term pain and disability. The baseline profile and change in status offered less predictive value

International low back pain guidelines: A comparison of two research based models of care for the management of acute low back pain.

Evidence based guidelines for the management of acute low back pain (ALBP) have been formulated by numerous countries. There are discrepancies between guidelines regarding physiotherapy treatment. The aim of this study was to compare two research based models derived from international LBP guidelines. A single-blind randomised controlled trial was undertaken in a physiotherapy outpatients department. Subjects with ALBP were randomly allocated to an ‘assess/advise/treat’ group (n = 50) or an ‘assess/advise/wait’ group (n = 52). The primary outcome measure was the Roland and Morris Disability Questionnaire (RMDQ). Secondary outcome measures of pain (VAS, usual pain intensity) depressive symptoms (MZSRDS) somatic distress (MSPQ) anxiety (STAIS) quality of life (SF36) and general health (EuroQol) were also obtained. Outcomes were assessed at 6-weeks, 3-months and 6-months. At 6-weeks subjects in the assess/advise/treat group demonstrated less LBP related disability (p = 0.02) and depressive symptoms (p = 0.01), as well as better general health (p = 0.006, p = 0.05), vitality (p \u3c 0.001), social functioning (p = 0.004) and mental health (p = 0.002). At long-term assessment (3 and 6 months) subjects in the assess/advise/treat group were less distressed (p = 0.004), anxious (p = 0.01) and had fewer depressive symptoms (p = 0.001), as well as reporting better general health (p = 0.009, p = 0.05), emotional role (p = 0.03) and mental health (p = 0.04). Active physiotherapy produces better short-term outcomes than advice. Delaying treatment has no long-term consequences on pain or disability, but affects the development of psychosocial features

Optimising physiotherapy care for acute low back pain – identifying non-responders to treatment

Recent evidence suggests that positive effects of physiotherapy for acute low back pain patients can be achieved if treatment is delivered early enough. However it is clear that not all patients treated with physiotherapy are likely to report equally positive outcomes from their treatment. The identification of clinical characteristics of those patients who do less well will help refine models of care for acute low back pain. Aim: To identify non-responders to early active physiotherapy. Method: A secondary analysis was conducted on the data from a recently published randomised controlled trial of early physiotherapy for acute low back pain. All patients were randomised into two groups: immediate physiotherapy or advice and wait list and completed a series of physical, psychological and pain measures at baseline and again at six weeks. Multivariate statistical analysis was conducted to identify which patient baseline characteristics were associated with unsuccessful outcomes at the six week follow up. Control group comparisons permitted only those relationships associated with the intervention to be described. Results: Data analysis indicated that subgroups of patients who responded poorly to their physiotherapy treatment could be identified by a priori knowledge of their pain, mental health and physical function (p\u3c0.05). Conclusions: The results of the current analysis suggest that there are identifiable subgroups of patients who respond less well to physiotherapy treatment. Attention to these patient characteristics needs to be included in models of care for acute low back pain so that effects of therapy for all patients can be optimised

Problematic clinical features of powered wheelchair users with severely disabling multiple sclerosis

This article is made available through the Brunel Open Access Publishing Fund. Copyright @ 2014 Informa UK Ltd.Purpose: The aim of this study is to describe the clinical features of powered wheelchair users with severely disabling multiple sclerosis (MS) and explore the problematic clinical features influencing prescription. Method: Retrospective review of electronic and case note records of recipients of electric-powered indoor/outdoor powered wheelchairs (EPIOCs) attending a specialist wheelchair service between June 2007 and September 2008. Records were reviewed by a consultant in rehabilitation medicine, data systematically extracted and entered into a computer database. Further data were entered from clinical records. Data were extracted under three themes; demographic, diagnostic, clinical and wheelchair factors. Results: Records of 28 men mean age 57 (range 37–78, SD 12) years and 63 women mean age 57 (range 35–81, SD 11) years with MS were reviewed a mean of 64 (range 0–131) months after receiving their wheelchair. Twenty two comorbidities, 11 features of MS and 8 features of disability were thought to influence wheelchair prescription. Fifteen users were provided with specialised seating and 46 with tilt-in-space seats. Conclusions: Our findings suggest that people with severe MS requiring an EPIOC benefit from a holistic assessment to identify problematic clinical features that influence the prescription of the EPIOC and further medical and therapeutic interventions

Rethinking clinical trials of transcranial direct current stimulation: Participant and assessor blinding is inadequate at intensities of 2mA

Copyright @ 2012 The Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and 85 reproduction in any medium, provided the original author and source are credited. The article was made available through the Brunel University Open Access Publishing Fund.Background: Many double-blind clinical trials of transcranial direct current stimulation (tDCS) use stimulus intensities of 2 mA despite the fact that blinding has not been formally validated under these conditions. The aim of this study was to test the assumption that sham 2 mA tDCS achieves effective blinding. Methods: A randomised double blind crossover trial. 100 tDCS-naïve healthy volunteers were incorrectly advised that they there were taking part in a trial of tDCS on word memory. Participants attended for two separate sessions. In each session, they completed a word memory task, then received active or sham tDCS (order randomised) at 2 mA stimulation intensity for 20 minutes and then repeated the word memory task. They then judged whether they believed they had received active stimulation and rated their confidence in that judgement. The blinded assessor noted when red marks were observed at the electrode sites post-stimulation. Results: tDCS at 2 mA was not effectively blinded. That is, participants correctly judged the stimulation condition greater than would be expected to by chance at both the first session (kappa level of agreement (κ) 0.28, 95% confidence interval (CI) 0.09 to 0.47 p = 0.005) and the second session (κ = 0.77, 95%CI 0.64 to 0.90), p = <0.001) indicating inadequate participant blinding. Redness at the reference electrode site was noticeable following active stimulation more than sham stimulation (session one, κ = 0.512, 95%CI 0.363 to 0.66, p<0.001; session two, κ = 0.677, 95%CI 0.534 to 0.82) indicating inadequate assessor blinding. Conclusions: Our results suggest that blinding in studies using tDCS at intensities of 2 mA is inadequate. Positive results from such studies should be interpreted with caution.GLM is supported by the National Health & Medical Research Council of Australia ID 571090

Early intervention for the management of acute low back pain: A single blind randomised controlled trial of biopsychosocial education, manual therapy and exercise

Design: A single blind randomised controlled trial comparing two models of care for patients with simple acute low back pain (ALBP). Objectives: To compare two research-based models of care for ALBP, and investigate the effect of the timing of physical intervention. Summary of Background Data National guidelines offer conflicting information on the delivery of physical treatment in the management of ALBP. Review of guidelines suggests two different models of care. Direct comparisons between these models are lacking in the literature. The present study aims to compare these two approaches to the management of ALBP. Method: Among 804 referred patients, 102 subjects met the specific admission criteria and were randomly assigned to an ‘assess/advise/treat’ group or an ‘assess/advise/wait’ group. The intervention consisted of biopsychosocial education, manual therapy and exercise. Assessment of short-term outcome enables comparison to be made between intervention and advice to stay active. Assessment of long-term outcome enables comparison to be made between early and late intervention. Study outcomes of reported pain (VAS), functional disability (RMDQ), mood (MZSRDS, MSPQ, STAIS), general health (Euroqol) and quality of life (SF-36) were assessed at baseline, six weeks, three months and six months. Results: At six weeks, the ‘assess/advise/treat’ group demonstrated greater improvements in disability, mood, general health and quality of life than patients in the ‘assess/advise/wait’ group (p0.05). However, mood, general health and quality of life remained significantly better in the ‘assess/advise/treat’ group (p\u3c0.05). Conclusions: At six weeks physiotherapy intervention is more effective than advice on staying active, leading to more rapid improvement in function, mood, quality of life and general health. The timing of intervention affects the progression of psychosocial features. If treatment is provided later, the same psychosocial benefits are not achieved. Therefore an \u27assess/advise/treat\u27 model of care seems to offer better outcomes than an \u27assess/advise/wait\u27 model of care

Flipping the ICF: Exploring the Interplay of Theory and the Lived Experience to Reconsider Physical Activity in Community-Dwelling People With Multiple Sclerosis

People with multiple sclerosis (MS) report lower physical activity levels and are at a risk of becoming sedentary. As such, they are at an increased risk of developing secondary health conditions associated with inactivity. This is of major public health concern. Attempts to improve the physical activity levels in people with MS remain a challenge for health professionals. One key reason might be the lack of understanding about the meanings people with MS ascribe to exercise and physical activity. This paper draws on the key findings of a three-phased interconnected mixed methods sequential explanatory study to examine the meanings of exercise and physical activity from the perspectives of people with MS and health professionals. Phase 1 used a four-round Delphi questionnaire to scope and determine the consensus of priorities for exercise and physical activity and the reasons why people with MS (N = 101) engaged in these activities. Phase 2 used face-to-face semistructured interviews of people with MS (N = 16) to explore the meanings ascribed to exercise and physical activity. Phase 3 explored the perceptions of physiotherapists (N = 14) about exercise and physical activity using three focus groups. Using the International Classification of Functioning, Disability, and Health as a theoretical framework to underpin this study, the authors discuss the key factors, for example, emphasis on the contextual factors, that drive decision making around exercise and physical activity participation in people with MS and explore the clinical implications to health professionals

Transcranial direct current stimulation of the motor cortex in the treatment of chronic non-specific low back pain. A randomised, double-blind exploratory study

This exploratory study aimed to test the proof of principle that active anodal transcranial direct current stimulation (tDCS) applied to the motor cortex reduces pain significantly more than sham stimulation in a group of participants with chronic non-specific low back pain

Non-invasive brain stimulation techniques for chronic pain. A Cochrane systematic review and meta-analysis

Poster Presentation Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES) and transcranial direct current stimulation (tDCS). These approaches to pain treatment are relatively novel. It is important to assess the existing literature robustly to ascertain the current level of supporting evidence and to inform future research and potential clinical use

The pain experiences of powered wheelchair users

Copyright © 2012 Informa UK, Ltd. This is the author's accepted manuscript. The final published article is available from the link below.Purpose: To explore the experience of pain and discomfort in users of electric-powered indoor/outdoor wheelchairs (EPIOCs) provided by a National Health Service. Methods: EPIOC users receiving their chair between February and November 2002 (N=74) were invited to participate in a telephone questionnaire/interview and 64 (aged 1081 years) agreed. Both specific and open-ended questions examined the presence of pain/discomfort, its severity, minimizing and aggravating factors, particularly in relation to the EPIOC and its use. Results: Most EPIOC users described experiences of pain with 17% reporting severe pain. Over half felt their pain was influenced by the wheelchair and few (25%) considered their chair eased their symptoms. The most common strategy for pain relief was taking medication. Other self-help strategies included changing position, exercise and complementary therapies. Respondents emphasized the provision of backrests, armrests, footrests and cushions which might alleviate or exacerbate pain, highlighting the importance of appropriate assessment for this high dependency group. Conclusions: Users related pain to their underlying medical condition, their wheelchair or a combination of the two. User feedback is essential to ensure that the EPIOC meets health needs with minimal pain. This becomes more important as the health condition of users changes over time