Validation of the French Version of the "Patterns of Activity Measure" in Patients with Chronic Musculoskeletal Pain.

Background. The "Patterns of Activity Measure" (POAM-P) is a self-administered questionnaire that assesses "avoidance", "pacing" and "overdoing" activity patterns in chronic pain patients. Objectives. To adapt the POAM-P to French ("POAM-P/F") and test its validity and reliability in Chronic Musculo-Skeletal Pain patients (CMSP). Methods. We followed the recommended procedure for translation of questionnaires. Five hundred and ninety five inpatients, admitted to a tertiary rehab center in the French-speaking part of Switzerland for chronic pain after orthopedic trauma, were included (sex ratio M/F = 4.36, mean age 43 ± 12). Face, content and criterion validities, internal consistency and reliability were assessed. Data included: TAMPA Scale for Kinesiophobia (TSK), Chronic Pain Coping Inventory (CPCI), Pain Catastrophizing Scale (PCS), Brief Pain Inventory (BPI), Hospital Anxiety and Depression Scale (HADS). Results. Face and content validities were checked during the translation process. Correlations between POAM-P/F-avoidance and TSK, POAM-P/F-pacing and CPCI-pacing, POAM-P/F-overdoing and CPCI-task persistence were highly significant (r > 0.3, p < 10(-2)). The three subscales demonstrated excellent homogeneity (Cronbach's alpha coefficients > 0.8) and test-retest reliability (Intraclass Correlation Coefficients > 0.8). They correlated very differently with the other scales. Discussion and Conclusion. The three POAM-P/F subscales clearly assess different behaviors in CMSP. The POAM-P/F is a suitable questionnaire for classifying French speaking CMSP into avoiders, pacers or overdoers

Subjective perceptions as prognostic factors of time to fitness for work during a 4-year period after inpatient rehabilitation for orthopaedic trauma.

INTRODUCTION: Time to fitness for work (TFW) was measured as the number of days that were paid as compensation for work disability during the 4 years after discharge from the rehabilitation clinic in a population of patients hospitalised for rehabilitation after orthopaedic trauma. The aim of this study was to test whether some psychological variables can be used as potential early prognostic factors of TFW. MATERIAL AND METHODS: A Cox proportional hazards model was used to estimate the associations between predictive variables and TFW. Predictors were global health, pain at hospitalisation and pain decrease during the stay (all continuous and standardised by subtracting the mean and dividing by two standard deviations), perceived severity of the trauma and expectation of a positive evolution (both binary variables). RESULTS: Full data were available for 807 inpatients (660 men, 147 women). TFW was positively associated with better perceived health (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.13-1.19), pain decrease (HR 1.46, 95% CI 1.30-1.64) and expectation of a positive evolution (HR 1.50, 95% CI 1.32-1.70) and negatively associated with pain at hospitalisation (HR 0.67, 95% CI 0.59-0.76) and high perceived severity (HR 0.72, 95% CI 0.61-0.85). DISCUSSION: The present results provide some evidence that work disability during a four-year period after rehabilitation may be predicted by prerehabilitation perceptions of general health, pain, injury severity, as well as positive expectation of evolution

Predicting Non Return to Work after Orthopaedic Trauma: The Wallis Occupational Rehabilitation RisK (WORRK) Model.

BACKGROUND: Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker's background. METHODS: Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients' data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests. RESULTS: At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate. CONCLUSIONS: Non-RTW may be predicted with a simple model constructed with variables independent of the patient's education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers

Avoidance, pacing, or persistence in multidisciplinary functional rehabilitation for chronic musculoskeletal pain: An observational study with cross-sectional and longitudinal analyses.

Three main activity patterns have been distinguished in describing chronic pain (avoidance, pacing and persistence). However, their influence on patient outcomes remains a question of debate. This observational study aimed to measure the associations between the avoidance, pacing, and persistence (labelled overdoing) scales of the Patterns of Activity Measure-Pain (POAM-P), self-reported outcomes (pain-interference, depression, functional ability), and observational outcomes (walking, lifting test, physical fitness). We conducted an observational study with cross-sectional and longitudinal analyses. The data were collected prospectively before and after treatment, which was a 5-week functional rehabilitation including vocational aspects. In addition to self-reported and observational outcomes, patients were asked if they thought they would be able to return to work at 6 months. Analyses were conducted with treatment effect sizes, correlations, and multiple regression models. In this sample (891 patients), we found on average small to moderate improvements for pain-interference and observational outcomes (Cohen's d: 0.37 to 0.64). According to the multivariable models, overdoing was associated with most of the beneficial psychosocial and observational outcomes (β -0.13 to 0.17; all p<0.01). Avoidance was related to negative psychosocial outcomes before treatment (β -0.09 to 0.17; all p<0.015). Pacing, which had moderate correlation with avoidance (r = 0.46), was not associated with most of the outcomes. The feeling that the goal of returning to work was attainable was associated with lower avoidance scores (adjusted OR 0.97; p = 0.024). The overdoing POAM-P scale probably measures a task-contingent persistence, which appears appropriate in the setting of this study. Persistent behavior was indeed related to small or moderate positive biopsychosocial outcomes, before and after treatment. Moreover feeling able to return to work was related to lower avoidance. Further studies should test the efficacy of motivational strategies that may promote functional task-contingent persistence and reduce avoidance of painful tasks

Activity patterns among patients with chronic pain after orthopaedic trauma

ObjectivesActivity patterns influence the development and perpetuation of musculoskeletal pain. To date, three major patterns have been observed in particular on chronic low back pain patients: avoidance, pacing and persistence. Relationships between these behaviours and clinical outcomes remain inconclusive. Moreover, there is only few data on other chronic pain syndromes. Our aim was to identify activity patterns in patients with chronic pain after orthopaedic trauma and to describe relationships with pain, depressive symptomatology and disability.Patients and methodsParticipants were rehab orthopaedic trauma inpatients with chronic pain (mean duration: 9 months). Activity patterns classification was made at entry with the “Patterns of Activity Measure-Pain” (POAM-P) and the Tampa scale for Kinesiophobia (TSK). Outcomes were assessed with the Brief Pain Inventory (BPI), the Hospital Anxiety and Depression scale (HADS), the Spinal Function Sort (SFS: spinal and lower limb trauma) and the Hand Function Sort (HFS: upper limb trauma). Descriptive statistics and ANOVA were used.Results497 inpatients were included (mean age: 43 years; female: 22%). Patterns distribution was: 46% avoidance; 30% pacing and 24% persistence. Kinesiophobia (TSK≥45points) is much more marked in avoidance (71%). Nevertheless, 37% in pacing, 22% in persistence also have kinesiophobia which may suggest the existence of more than three patterns. Outcomes were always poor in avoidance, intermediate in pacing and better in persistence behaviour.DiscussionThe 3 main activity patterns were identified in rehab orthopaedic trauma inpatients. In this cross-sectional study, persistence behaviour was associated with better self-perceptions

Clinician and Patient-reported Outcomes Are Associated With Psychological Factors in Patients With Chronic Shoulder Pain.

Validated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors. We asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements? All new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months (interquartile range, 5.5-15 months), and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries (59%, 93 patients) and were followed for a mean of 31.6 days (SD, 7.5 days). Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment (physiotherapy, cognitive therapy and vocational training). The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes. Greater disability on the DASH was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.64; 95% CI, 0.25-1.03; p = 0.002) and social factors (language, professional qualification combined coefficient, -6.15; 95% CI, -11.09 to -1.22; p = 0.015). Greater pain on the Brief Pain Inventory was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.076; 95% CI, 0.021-0.13; p = 0.006). Poorer impression of change was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia coefficient, 0.93; 95% CI, 0.87-0.99; p = 0.026) and social factors (education, language, and professional qualification coefficient, 6.67; 95% CI, 2.77-16.10; p < 0.001). Worse clinician-rated outcome was associated only with psychological factors (Hospital Anxiety and Depression Scale (depression only), Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, -0.35; 95% CI, -0.58 to -0.12; p = 0.003). Depressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score. Level III, prognostic study

Psychiatric Comorbidity and Complex Regional Pain Syndrome Through the Lens of the Biopsychosocial Model: A Comparative Study.

To compare the prevalence of psychiatric comorbidity between patients with complex regional pain syndrome (CRPS) of the hand and non-CRPS patients and to assess the association between biopsychosocial (BPS) complexity profiles and psychiatric comorbidity in a comparative study. We included a total of 103 patients with CRPS of the hand and 290 patients with chronic hand impairments but without CRPS. Psychiatric comorbidities were diagnosed by a psychiatrist, and BPS complexity was measured by means of the INTERMED. The odds ratios (OR) of having psychiatric comorbidities according to BPS complexity were calculated with multiple logistic regression (adjusted for age, sex, and pain). Prevalence of psychiatric comorbidity was 29% in CRPS patients, which was not significantly higher than in non-CRPS patients (21%, relative risk=1.38, 95% CI: 0.95 to 2.01 p=0.10). The median total scores of the INTERMED were the same in both groups (23 points). INTERMED total scores (0-60 points) were related to an increased risk of having psychiatric comorbidity in CRPS patients (OR=1.46; 95% CI: 1.23-1.73) and in non-CRPS patients (OR=1.21; 95% CI: 1.13-1.30). The four INTERMED subscales (biological, psychological, social, and health care) were correlated with a higher risk of having psychiatric comorbidity in both groups. The differences in the OR of having psychiatric comorbidity in relation to INTERMED total and subscale scores were not statistically different between the two groups. The total scores, as well as all four dimensions of BPS complexity measured by the INTERMED, were associated with psychiatric comorbidity, with comparable magnitudes of association between the CRPS and non-CRPS groups. The INTERMED was useful in screening for psychological vulnerability in the two groups

The self-assessment INTERMED predicts healthcare and social costs of orthopaedic trauma patients with persistent impairments.

To use the self-assessment INTERMED questionnaire to determine the relationship between biopsychosocial complexity and healthcare and social costs of patients after orthopaedic trauma. Secondary prospective analysis based on the validation study cohort of the self-assessment INTERMED questionnaire. Inpatients orthopaedic rehabilitation with vocational aspects. In total, 136 patients with chronic pain and impairments were included in this study: mean (SD) age, 42.6 (10.7) years; 116 men, with moderate pain intensity (51/100); suffering from upper (n = 55), lower-limb (n = 51) or spine (n = 30) pain after orthopaedic trauma; with minor or moderate injury severity (severe injury for 25). Biopsychosocial complexity, assessed with the self-assessment INTERMED questionnaire, and other confounding variables collected prospectively during rehabilitation. Outcome measures (healthcare costs, loss of wage costs and time for fitness-to-work) were collected through insurance files after case settlements. Linear multiple regression models adjusted for age, gender, pain, trauma severity, education and employment contract were performed to measure the influence of biopsychosocial complexity on the three outcome variables. High-cost patients were older (+3.6 years) and more anxious (9.0 vs 7.3 points at HADS-A), came later to rehabilitation (+105 days), and showed higher biopsychosocial complexity (+3.2 points). After adjustment, biopsychosocial complexity was significantly associated with healthcare (ß = 0.02; P = 0.003; exp <sup>ß</sup> = 1.02) and social costs (ß = 0.03; P = 0.006, exp <sup>ß</sup> = 1.03) and duration before fitness-to-work (ß = 0.04; P < 0.001, exp <sup>ß</sup> = 1.04). Biopsychosocial complexity assessed with the self-assessment INTERMED questionnaire is associated with higher healthcare and social costs

Evaluation of therapists’ individual characteristics’ influence on recommendations to CLBP patients

IntroductionThis study measured different therapists’ biopsychosocial parameters and their influence on treatment recommendations for chronic low back pain (CLBP) patients. Based on previous studies and with a biopsychosocial approach, this work aimed to understand the variations in recommendations depending on personal dispositions.MethodsEighty-two therapists (aged 37±11 years, 34 men/48 women) were recruited within our rehabilitation clinic (CRR). Their physical activity was objectively assessed by tri-axial accelerometry and questionnaires have been used to evaluate the following variables: subjective physical activity (BAECKE), pain attitudes and beliefs (TSK and POAM-P), anxiety and depression (HADS), uncertainty intolerance (EII) and social desirability (MC-SDS). Objective stress level was measured by salivary cortisol.In order to measure the variability in recommendations, 3 validated vignettes for CLBP patients management were distributed.ResultsBehavioural patterns coping with pain (Avoidance, Overdoing and Pacing) do occur in therapists (10% Avoidance, 47% Pacing and 43% Overdoing) and do affect recommendations’ application. These 3 different patterns are also related to age, sex, BMI, depression and physical activity. Others relations are currently being analysed.ConclusionThis study suggests that we could categorise therapists depending onidiosyncratics variablespersonal dispositions. This classification would determine recommendations orientation for physical and professional activity. For future research studies, it would be interesting to deal in depth with these relations in order to individualize recommendations to get a better rehabilitation procedure

Adapting the "Chester step test" to predict peak oxygen uptake in children.

Maximal exercise testing may be difficult to perform in clinical practice, especially in obese children who have low cardiorespiratory fitness and exercise tolerance. We aimed to elaborate a model predicting peak oxygen consumption (VO2) in lean and obese children with use of the submaximal Chester step test. We performed a maximal step test, which consisted of 2-minute stages with increasing intensity to exhaustion, in 169 lean and obese children (age range: 7-16 years). VO2 was measured with indirect calorimetry. A statistical Tobit model was used to predict VO2 from age, gender, body mass index (BMI) z-score and intensity levels. Estimated VO2peak was then determined from the heart rate-VO2 linear relationship extrapolated to maximal heart rate (220 minus age, in beats.min-1). VO2 (ml/kg/min) can be predicted using the following equation: VO2 = 22.82 - [0.68*BMI z-score] - [0.46*age (years)] - [0.93*gender (male = 0; female = 1)] + [4.07*intensity level (stage 1, 2, 3 etc.)] - [0.24*BMI z-score *intensity level] - [0.34*gender*intensity level]. VO2 was lower in participants with high BMI z-scores and in female subjects. The Chester step test can assess cardiorespiratory fitness in lean and obese children in clinical settings. Our adapted equation allows the Chester step test to be used to estimate peak aerobic capacity in children