The influence of comorbidities on the treatment outcome in symptomatic lumbar spinal stenosis: A systematic review and meta-analysis

Background Lumbar spinal stenosis (LSS) affects mainly elderly patients. To this day, it is unclear whether comorbidities influence treatment success. The aim of this systematic review and meta-analysis was to assess the impact of comorbidities on the treatment effectiveness in symptomatic LSS. Methods We conducted a systematic review and meta-analysis and reviewed prospective or retrospective studies from Medline, Embase, Cochrane Library and CINAHL from inception to May 2020, including adult patients with LSS undergoing surgical or conservative treatment. Main outcomes were satisfaction, functional and symptoms improvement, and adverse events (AE). Proportions of outcomes within two subgroups of a comorbidity were compared with risk ratio (RR) as summary measure. Availability of ≥3 studies for the same subgroup and outcome was required for meta-analysis. Results Of 72 publications, 51 studies, mostly assessing surgery, there was no evidence reported that patients with comorbidities were less satisfied compared to patients without comorbidities (RR 1.06, 95% confidence interval (CI) 0.77 to 1.45, 94%), but they had an increased risk for AE (RR 1.46, 95% CI 1.06 to 2.01, 72%). A limited number of studies found no influence of comorbidities on functional and symptoms improvement. Older age did not affect satisfaction, symptoms and functional improvement, and AE (age >80 years RR 1.22, 95% CI 0.98 to 1.52, 60%). Diabetes was associated with more AE (RR 1.72, 95% CI 1.19 to 2.47, 58%). Conclusion In patients with LSS and comorbidities (in particular diabetes), a higher risk for AE should be considered in the treatment decision. Older age alone was not associated with an increased risk for AE, less functional and symptoms improvement, and less treatment satisfaction

A definition of flare in low back pain (LBP): A multiphase process involving perspectives of individuals with LBP and expert consensus

Low back pain (LBP) varies over time. Consumers, clinicians and researchers use various terms to describe fluctuations of LBP symptoms. Although "flare" is commonly used to describe symptom fluctuation, there is no consensus on how it is defined. This study aimed to obtain consensus for a LBP flare definition using a mixed-method approach. Step 1 involved derivation of a preliminary candidate flare definition based on thematic analysis of consumers' views in consultation with an expert consumer writer. In Step 2, a workshop was conducted to incorporate perspectives of LBP experts into the preliminary flare definition, which resulted in two alternative LBP flare definitions. Step 3 refined the definition using a two-round Delphi consensus process with experts in musculoskeletal conditions. The definition favoured by experts was further tested with individuals with LBP in Step 4, using the definition in three scenarios. This multiphase study produced a LBP flare definition that distinguishes it from other LBP fluctuations, represents views of consumers, involves expert consensus, and is understandable by consumers in clinical and research contexts: "A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions". Perspective: A multiphase processes produced a low back pain (LBP) flare definition that distinguishes it from other LBP fluctuations, involves expert consensus and represents consumers' views

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

Recurrent low-back pain : Exercise intervention and predictive factors

Low-back pain continues to be one of the main problems for which subjects seek treatment in primary care. While the natural history of low-back pain is often considered to be good, many sufferers get further episodes that affect well-being as well as quality of life. Aim: The main aim of the work presented in this thesis was to evaluate the efficacy of a graded exercise intervention in a sample of subjects with recurrent low-back pain still at work, and to investigate factors predicting future outcome of disability and pain. Methods: One-hundred-and-eighteen subjects with recurrent low-back pain participated. In addition, Study I included 57 healthy age- and gender-matched controls. Pre-intervention, post-intervention, 6-month, 12-month (Studies II, III, IV) and 36-month (Study III) follow-ups evaluated pain, disability, physical health, fear-avoidance beliefs and self-efficacy beliefs. Self-rated questionnaires were used. Level of aerobic fitness was compared between the group with low-back pain and healthy controls (Study I), and a graded exercise intervention emphasizing stabilizing exercises was evaluated in comparison with either manual treatment (Study II) or daily walks (Study III). Predictive factors for a future outcome of disability and pain were investigated using multivariate regression analysis (Study IV). Results: There was no difference in aerobic fitness level between subjects with low-back pain and healthy controls. In the group with LBP, regression analysis showed an association between a lower level of aerobic fitness and higher age, gender and lower levels of selfefficacy (Study I). In Study II, comparing a graded exercise intervention with manual treatment, a significant difference in favour of the exercise group regarding disability after the treatment was maintained in the long term. No significant difference emerged between the groups regarding pain. (Study II). In Study III, between-group testing showed significant differences in favour of the exercise group for perceived disability at 12-months, maintained at the 36-month follow-up. In addition, between-group results for pain showed greater reduction for the exercise group post-intervention than for the daily-walks group. Regarding secondary outcome, the results showed a significant group difference in favour of the exercise group in short- and long term regarding physical health and in self rated selfefficacy at 12- and 36-month follow-ups. Regarding fear-avoidance, no such differences emerged (Study III). Lower levels of self-efficacy, higher levels of perceived disability painlevel and pain frequency emerged as predictors of an unfavourable clinical outcome, and these predictors remained significant in the post-intervention models. (Study IV). Conclusion: In conclusion, a graded exercise intervention emphasizing stabilizing exercises alleviated disability levels and improved physical health and rated self-efficacy more than manual treatment or daily walks did, in subjects with recurrent low-back pain and currently at work. The graded exercises also reduced recurrent need for treatment in the long term, indicating that the exercises had a preventive effect. Levels of aerobic fitness were comparable between the subjects with low-back pain and the healthy controls. However, lower levels of aerobic fitness were associated with higher age, gender and low self-efficacy in the sample of subjects with low-back pain. Importantly, higher levels of perceived pain, pain frequency and disability and a lower level of self-efficacy emerged as predictors of an unfavourable outcome of disability and pain in the long term, indicating that such early screening information might be useful for further management of patients with LBP

Are respiratory disorders risk factors for troublesome neck/shoulder pain? : A study of a general population cohort in Sweden

PURPOSE: The etiology of neck/shoulder pain is complex. Our purpose was to investigate if respiratory disorders are risk factors for troublesome neck/shoulder pain in people with no or occasional neck/shoulder pain. METHODS: This prospective cohort study was based on the Stockholm Public Health Cohorts (SPHC) 2006/2010 and the SPHC 2010/2014. We included adults who at baseline reported no or occasional neck/shoulder pain in the last six months, from the two subsamples (SPHC 06/10 n = 15 155: and SPHC 2010/14 n = 25 273). Exposures were self-reported asthma at baseline in SPHC 06/10 and Chronic Obstructive Pulmonary Disease (COPD) at baseline in SPHC 10/14. The outcome was having experienced at least one period of troublesome neck/shoulder pain which restricted work capacity or hindered daily activities to some or to a high degree during the past six months, asked for four years later. Binomial regression analyses were used to calculate risk ratios (RR) with 95% confidence intervals (95% CI). RESULTS: Adjusted results indicate that those reporting to suffer from asthma at baseline had a higher risk of troublesome neck/shoulder pain at follow-up four years later (RR 1.48, 95% CI 1.10-2.01) as did those reporting to suffer from COPD (RR 2.12 95%CI 1.54-2.93). CONCLUSION: Our findings indicate that those with no or occasional neck/shoulder pain and reporting to suffer from asthma or COPD increase the risk for troublesome neck/shoulder pain over time. This highlights the importance of taking a multi-morbidity perspective into consideration in health care. Future longitudinal studies are needed to confirm our findings

Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags - A Systematic Review.

BACKGROUND Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED. METHODS We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality. RESULTS We analyzed 22 studies with a total of 41'320 patients. The prevalence of any serious spinal pathology requiring immediate/urgent treatment was 2.5-5.1% in prospective and 0.7-7.4% in retrospective studies (0.0-7.2% for vertebral fractures, 0.0-2.1% for spinal cancer, 0.0-1.9% for infectious disorders, 0.1-1.9% for pathologies with spinal cord/cauda equina compression, 0.0-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were: suspicion and/or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, other infection site (epidural abscess). CONCLUSION We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high quality prospective studies is needed

Psychometric properties of the Swedish version of the TreatmentOutcome Satisfaction Questionnaire

PURPOSE: Patient satisfaction is an outcome measure for low-back pain (LBP) interventions which allows clinicians to design patient-oriented treatments. The Treatment Outcome Satisfaction Questionnaire (TOSQ) is an English instrument constructed for such evaluations, and no equivalent instruments exist for the Swedish population. This study, therefore, translated TOSQ into Swedish and assessed the translated version's psychometric properties for patients with LBP. METHODS: A cross-cultural adaptation was used to translate TOSQ into Swedish. Subsequently, data from 131 patients with LBP whom undergone physiotherapy were consecutively aggregated and analyzed in a Rasch rating scale model with person measures standardized at 0-100 logits to evaluate the translated scale's validity. Finally, test-retest reliability of the Swedish version of TOSQ (TOSQ-S) was quantified via an intraclass correlation coefficient (ICC) and the standard error of measurement (SEM) in 41 patients. RESULTS: TOSQ was successfully translated into Swedish; however, while some Rasch model indices supported the translated scale's unidimensionality, one out of eight items and 12 out of 131 subjects misfitted the model. Scale optimization resulted in a 6-item subconfiguration, for which all items fitted the model, person misfits were reduced to ten subjects, and the person separation index increased from 1.86 to 2.04. ICC and SEM estimates suggested acceptable reliability for the six-item TOSQ-S at 0.66 and 6.6 logits, respectively. CONCLUSIONS: A six-item TOSQ-S configuration showed acceptable psychometric properties and is suitable for measuring treatment outcome satisfaction of physiotherapy in patients with LBP.QC 20161227</p

Visual assessment of movement quality in the single leg squat test: a review and meta-analysis of inter-rater and intrarater reliability

ObjectivesTo conduct a review and meta-analysis on the inter-rater and intrarater reliability of the SLS, including the lateral step-down (LSD) and forward step-down (FSD) tests.DesignReview with meta-analysis.Data sourcesCINAHL, Cochrane Library, Embase, Medline (OVID) and Web of Science was searched up until December 2018.Eligibility criteriaStudies were eligible for inclusion if they were methodological studies which assessed the inter-rater and/or intrarater reliability of the SLS, FSD and LSD through observation of movement quality.ResultsThirty-one studies were included. The reliability varied largely between studies (inter-rater: kappa/intraclass correlation coefficients (ICC) = 0.00–0.95; intrarater: kappa/ICC = 0.13–1.00), but most of the studies reached ‘moderate’ measures of agreement. The pooled results of ICC/kappa showed a ‘moderate’ agreement for inter-rater reliability, 0.58 (95% CI 0.50 to 0.65), and a ‘substantial’ agreement for intrarater reliability, 0.68 (95% CI 0.60 to 0.74). Subgroup analyses showed a higher pooled agreement for inter-rater reliability of ≤3-point rating scales while no difference was found for different numbers of segmental assessments.ConclusionOur findings indicate that the SLS test including the FSD and LSD tests can be suitable for clinical use regardless of number of observed segments and particularly with a ≤3-point rating scale. Since most of the included studies were affected with some form of methodological bias, our findings must be interpreted with caution.PROSPERO registration numberCRD42018077822

Visual assessment of movement quality: a study on intra- and interrater reliability of a multi-segmental single leg squat test

Abstract Background The Single Leg Squat test (SLS) is a common tool used in clinical examination to set and evaluate rehabilitation goals, but there is not one established SLS test used in the clinic. Based on previous scientific findings on the reliability of the SLS test and with a methodological rigorous setup, the aim of the present study was to investigate the intra- and interrater reliability of a standardised multi-segmental SLS test. Methods We performed a study of measurement properties to investigate the intra- and interrater reliability of a standardised multi-segmental SLS test including the assessment of the foot, knee, pelvis, and trunk. Novice and experienced physiotherapists rated 65 video recorded SLS tests from 34 test persons. We followed the Quality Appraisal for Reliability Studies checklist. Results Regardless of the raters experience, the interrater reliability varied between “moderate” for the knee variable (ĸ = 0.41, 95% CI 0.10–0.72) and “almost perfect” for the foot (ĸ = 1.00, 95% CI 1.00–1.00). The intrarater reliability varied between “slight” (pelvic variable; ĸ = 0.17, 95% CI -0.22-0.55) to “almost perfect” (foot variable; ĸ = 1.00, 95% CI 1.00–1.00; trunk variable; ĸ = 0.82, 95% CI 0.66–0.97). A generalised kappa coefficient including the values from all raters and segments reached “moderate” interrater reliability (ĸ = 0.52, 95% CI 0.43–0.61), the corresponding value for the intrarater reliability reached “almost perfect” (ĸ = 0.82, 95% CI 0.77–0.86). Conclusions The present study shows a “moderate” interrater reliability and an “almost perfect” intrarater reliability for the variable all segments regardless of the raters experience. Thus, we conclude that the proposed standardised multi-segmental SLS test is reliable enough to be used in an active population