Neuromuscular electrical stimulation to combat cognitive aging in people with spinal cord injury: protocol for a single case experimental design study.

INTRODUCTION: Individuals with spinal cord injury (SCI) can experience accelerated cognitive aging. Myokines (factors released from muscle cells during contractions), such as brain-derived neurotrophic factor (BDNF), are thought to have beneficial effects on cognition. Neuromuscular electrical stimulation (NMES) was shown to elicit a large release of myokines. However, the effects of NMES on cognitive function have not been studied. OBJECTIVE: To present the study protocol for a clinical trial evaluating the effects of NMES aimed at improving cognition and BDNF. METHODS: A replicated randomized three-phases single-case experimental design (SCED) with sequential multiple baseline time series and a single-armed prospective trial will be conducted with 15 adults with chronic SCI (> 12 months after injury) above L1 neurological level undergoing 30-min quadriceps NMES, 3 days per week for 12 weeks. MAIN STUDY ENDPOINTS: Primary endpoint is cognitive performance (assessed by a smartphone test) conducted three times per week during the baseline phase with random duration of 3 to 8 weeks, the intervention phase of 12 weeks, and the follow-up phase of 3 weeks after a no measurement rest period of 12 weeks. Secondary endpoints are changes in BDNF levels and cognitive performance measured before the baseline period, before and after intervention and after a 12 weeks follow-up. CONCLUSION: This will be the first study investigating the effects of 12 weeks NMES on both cognition and BDNF levels in individuals with SCI. The SCED results provide information on individual treatment effect courses which may direct future research. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05822297, 12/01/2023).

Exerkines and long-term synaptic potentiation: Mechanisms of exercise-induced neuroplasticity.

Physical exercise may improve cognitive function by modulating molecular and cellular mechanisms within the brain. We propose that the facilitation of long-term synaptic potentiation (LTP)-related pathways, by products induced by physical exercise (i.e., exerkines), is a crucial aspect of the exercise-effect on the brain. This review summarizes synaptic pathways that are activated by exerkines and may potentiate LTP. For a total of 16 exerkines, we indicated how blood and brain exerkine levels are altered depending on the type of physical exercise (i.e., cardiovascular or resistance exercise) and how they respond to a single bout (i.e., acute exercise) or multiple bouts of physical exercise (i.e., chronic exercise). This information may be used for designing individualized physical exercise programs. Finally, this review may serve to direct future research towards fundamental gaps in our current knowledge regarding the biophysical interactions between muscle activity and the brain at both cellular and system levels.

Acute Traumatic Stress Screening Can Identify Patients and Their Partners at Risk for Posttraumatic Stress Disorder Symptoms After a Cardiac Arrest: A Multicenter Prospective Cohort Study.

BACKGROUND: Posttraumatic stress disorder (PTSD) is prevalent in patients who have had a cardiac arrest and their partners. Accordingly, acute traumatic stress screening is recommended, but its association with later PTSD symptoms has never been addressed in postresuscitation settings. OBJECTIVE: The aim of this study was to examine whether acute traumatic stress is associated with PTSD symptoms in patients who have had a cardiac arrest and their partners. METHODS: This multicenter longitudinal study of 141 patients and 97 partners measures acute traumatic stress at 3 weeks and PTSD symptoms at 3 months and 1 year after resuscitation, using the Impact of Event Scale. Linear regression models were used to evaluate the association between severity of acute traumatic stress and PTSD symptoms and post hoc to explore effects of group (patients/partners), age, and sex on acute traumatic stress severity. We categorized Impact of Event Scale scores higher than 26 at 3 months and 1 year as clinical severe PTSD symptoms . RESULTS: Higher acute traumatic stress severity is significantly positively associated with higher PTSD symptom severity at 3 months (patients and partners: P < .001) and 1 year (patients and partners: P < .001) postresuscitation, with the strongest association for women compared with men ( P = .03). Acute traumatic stress was higher in women compared with men across groups ( P = .02). Clinical severe PTSD symptoms were present in 26% to 28% of patients and 45% to 48% of partners. CONCLUSION: Experiencing a cardiac arrest may elicit clinical severe PTSD symptoms in patients, but particularly in their partners. Screening patients and partners for acute traumatic stress postresuscitation is warranted to identify those at increased risk of long-term PTSD symptoms.

Functional Outcomes and Their Association With Physical Performance in Mechanically Ventilated Coronavirus Disease 2019 Survivors at 3 Months Following Hospital Discharge: A Cohort Study.

OBJECTIVES: We performed a comprehensive health assessment in mechanically ventilated coronavirus disease 2019 survivors to assess the impact of respiratory and skeletal muscle injury sustained during ICU stay on physical performance at 3 months following hospital discharge. DESIGN: Preregistered prospective observational cohort study. SETTING: University hospital ICU. PATIENTS: All mechanically ventilated coronavirus disease 2019 patients admitted to our ICU during the first European pandemic wave. MEASUREMENTS AND MAIN RESULTS: At 3 months after hospital discharge, 46 survivors underwent a comprehensive physical assessment (6-min walking distance, Medical Research Council sum score and handgrip strength), a full pulmonary function test, and a chest CT scan which was used to analyze skeletal muscle architecture. In addition, patient-reported outcomes measures were collected. Physical performance assessed by 6-minute walking distance was below 80% of predicted in 48% of patients. Patients with impaired physical performance had more muscle weakness (Medical Research Council sum score 53 [51-56] vs 59 [56-60]; p < 0.001), lower lung diffusing capacity (54% [44-66%] vs 68% of predicted [61-72% of predicted]; p = 0.002), and higher intermuscular adipose tissue area (p = 0.037). Reduced lung diffusing capacity and increased intermuscular adipose tissue were independently associated with physical performance. CONCLUSIONS: Physical disability is common at 3 months in severe coronavirus disease 2019 survivors. Lung diffusing capacity and intermuscular adipose tissue assessed on CT were independently associated with walking distance, suggesting a key role for pulmonary function and muscle quality in functional disability.

Effectiveness of an integrated multidisciplinary geriatric rehabilitation programme for older persons with stroke: a multicentre randomised controlled trial.

BACKGROUND: Almost half of the stroke patients admitted to geriatric rehabilitation has persisting problems after discharge. Currently, there is no evidence based geriatric rehabilitation programme available for older stroke patients, combining inpatient rehabilitation with adequate ambulatory aftercare in the community. Therefore, we developed an integrated multidisciplinary rehabilitation programme that includes aftercare for older persons with stroke. We evaluated the effectiveness of this newly developed rehabilitation programme in comparison to usual care. METHODS: A multicentre randomised controlled trial was conducted in eight geriatric rehabilitation stroke units and their collaborating partners in primary care. The study population involved stroke patients and their informal caregivers who were aged 65 or over, living in the community before admission to geriatric rehabilitation, and expected to be able to return home after discharge. The programme consisted of three modules: inpatient neurorehabilitation, home-based self-management training, and stroke education. For patients, daily activity (FAI) was assessed as primary outcome and functional dependence (Katz-15), perceived quality of life (SSQoL) and social participation (IPA) as secondary outcomes. Additionally, among informal caregivers perceived care burden (self-rated burden VAS), objective care burden (Erasmus iBMG), and quality of life (CarerQol), were assessed as secondary outcomes. RESULTS: In total 190 patients and 172 informal caregivers were included. Mean age of the patients in the intervention group was 78.9 years (SD = 7.0) and in the usual care group 79.0 years (SD = 6.5). Significant favourable effects for the programme were observed for the subscale autonomy outdoors of the IPA (- 2.15, P = .047, and for the informal caregivers perceived care burden (1.23, P = .048. For the primary outcome daily activity and the other secondary outcomes, no significant effects were observed. CONCLUSION: The integrated multidisciplinary programme had no effect on daily activity of older stroke patients. However, patients participating in the programme had a higher level of perceived autonomy of outdoor activities and their informal caregivers perceived a lower care burden. The programme might be promising in providing adequate (after) care, although adaptation of the programme is recommended to increase its feasibility and improve its effects. TRIAL REGISTRATION: Current Controlled Trials ISRCTN62286281 . Registered 19-3-2010.

Implementation of health education interventions at Dutch music schools.

A randomized controlled trial was conducted comparing the effects of a biopsychosocial course (PRESTO-Play) vs. physical activity promotion (PRESTO-Fit) to reduce disability related to musculoskeletal disorders in music students. The current study provides an external validation and a formative and process evaluation, allowing for a better interpretation of results. First, a group of experts was asked to complete a structured evaluation of design and content of the trial. Second, quantitative and qualitative data were analysed from different stakeholders (students, therapists and conservatory staff) using questionnaires, logs, field notes and emails to evaluate fidelity, dose delivered, dose received, reach and context. Results are presented descriptively. Two authors independently identified key responses that were merged into themes. Although no difference in disability was found between interventions, closer evaluation revealed that participants in PRESTO-Play reported that they learned about prevention of physical complaints and were more satisfied with course contents compared with PRESTO-Fit. Study design and contents of the interventions were found to be valid, with an appropriate dose delivered. Feedback from students and logs suggested that behavioural change and psychosocial principles in PRESTO-Play might have not been implemented optimally. Only moderate fidelity in both groups and too little contrast between interventions could have influenced results. Low attendance rates and a presumed lack of generalization further decreased possible effectiveness. Context greatly influenced implementation. Implementing a future health course with closer collaboration with the institution could optimize accessibility and communication, encourage attendance and enhance motivation for behavioural change.

Feasibility of an integrated multidisciplinary geriatric rehabilitation programme for older stroke patients: a process evaluation.

BACKGROUND: Almost half of the stroke patients admitted to geriatric rehabilitation has persisting problems after discharge. Currently, there is no evidence based geriatric rehabilitation programme available for older stroke patients, combining inpatient rehabilitation with adequate aftercare aimed at reducing the impact of persisting problems after discharge from a geriatric rehabilitation unit. Therefore, we developed an integrated multidisciplinary rehabilitation programme consisting of inpatient neurorehabilitation treatment using goal attainment scaling, home based self-management training, and group based stroke education for patients and informal caregivers. We performed a process evaluation to assess to what extent this programme was performed according to protocol. Furthermore, we assessed the participation of the patients in the programme, and the opinion of patients, informal caregivers and care professionals on the programme. METHODS: In this multimethod study, process data were collected by means of interviews, questionnaires, and registration forms among 97 older stroke patients, 89 informal caregivers, and 103 care professionals involved in the programme. RESULTS: A part of patients and informal caregivers did not receive all key elements of the programme. Almost all patients formulated rehabilitation goals, but among two thirds of the patients the goal attainment scaling method was used. Furthermore, the self-management training was considered rather complex and difficult to apply for frail elderly persons with stroke, and the percentage of therapy sessions performed in the patients' home environment was lower than planned. In addition, about a quarter of the patients and informal caregivers attended the education sessions. However, a majority of patients, informal caregivers and care professionals indicated the beneficial aspects of the programme. CONCLUSION: This study revealed that although the programme in general is perceived to be beneficial by patients, and informal and formal caregivers, the feasibility of the programme needs further attention. Because of persisting cognitive deficits and specific care needs in our frail and multimorbid target population, some widely used methods such as goal attainment scaling, and self-management training seemed not feasible in their current form. To optimize feasibility of the programme, it is recommended to tailor these elements more optimally to the population of frail older patients.

The (cost-)effectiveness and cost-utility of a novel integrative care initiative for patients with chronic musculoskeletal pain: the pragmatic trial protocol of Network Pain Rehabilitation Limburg.

BACKGROUND: Rehabilitation care for patients with chronic musculoskeletal pain (CMP) is not optimally organized. The Network Pain Rehabilitation Limburg 2.0 (NPRL2.0) provides integrated care with a biopsychosocial approach and strives to improve the Quadruple Aim outcomes: pain-related disability of patients with CMP; experiences of care of patients with CMP; meaning in the work of healthcare professionals; and healthcare costs. Firstly, in this study, the effectiveness (with regard to the functioning and participation of patients) of primary care for patients with CMP will be assessed, comparing care organized following the NPRL2.0 procedure with usual care. Secondly, the cost-effectiveness and cost-utility with regard to health-related quality of life and healthcare costs will be assessed. And thirdly, the effect of duration of participation in a local network in primary care will be studied. METHODS: In this pragmatic study, it is expected that two local networks with 105 patients will participate in the prospective cohort study and six local networks with 184 patients in the stepped-wedge based design. Healthcare professionals in the local networks will recruit patients. INCLUSION CRITERIA: age ≥ 18 years; having CMP; willing to improve functioning despite pain; and adequate Dutch literacy. EXCLUSION CRITERIA: pregnancy; and having a treatable medical or psychiatric disease. Patients will complete questionnaires at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4). Questionnaires at T1 and T4 will include the Pain Disability Index and Short Form Health Survey. Questionnaires at T1, T2, T3, and T4 will include the EQ-5D-5L, and iMTA Medical Consumption and Productivity Cost Questionnaires. Outcomes will be compared using linear mixed-model analysis and costs will be compared using bootstrapping methods. DISCUSSION: NPRL2.0 is a multidimensional, complex intervention, executed in daily practice, and therefore needing a pragmatic study design. The current study will assess NPRL2.0 with respect to the Quadruple Aim outcomes: patient health and costs. This will provide more information on the (cost-) effectiveness of the organization of care in a network structure regarding patients with CMP. The other two Quadruple Aim outcomes will be examined alongside this study. Trial registration Netherlands Trial Register: NL7643. https://www.trialregister.nl/trial/7643 .

Factors associated with successful home discharge after inpatient rehabilitation in frail older stroke patients.

BACKGROUND: Stroke is a highly prevalent disease among older people and can have a major impact on daily functioning and quality of life. When community-dwelling older people are hospitalized due to stroke, discharge to an intermediate care facility for geriatric rehabilitation is indicated when return to the previous living situation is expected but not yet possible. However, a substantial proportion is still unable to return home after discharge and has to be admitted to a residential care setting. This study aims to identify which factors are associated with home discharge after inpatient rehabilitation among frail and multimorbid older stroke patients. METHODS: This study is a longitudinal cohort study among 92 community-dwelling stroke patients aged 65 years or over. All patients were admitted to one of eight participating intermediate care facilities for geriatric rehabilitation, under the expectation to return home after rehabilitation. We examined whether 16 potentially relevant factors (age; sex; household situation before admission; stroke history; cardiovascular disorders; diabetes mellitus; multimorbidity; cognitive disability; neglect; apraxia; dysphagia; urinary and bowel incontinence; emotional problems; sitting balance; daily activity level; and independence in activities of daily living) measured at admission were associated with discharge to the former living situation. Logistic regression analysis was used for statistical analysis. RESULTS: Mean age of the patients was 79.0 years (SD 6.4) and 51.1% was female. A total of 71 patients (77.1%) were discharged to the former living situation within 6 months after the start of geriatric rehabilitation. Of the 16 factors analysed, only a higher level of independence in activities of daily living at admission was significantly associated with home discharge. CONCLUSIONS: Our study shows that the vast majority of previously identified factors predicting home discharge among stroke patients, could not predict home discharge among a group of frail and multimorbid older persons admitted to geriatric rehabilitation. Only a higher level of independence in activities of daily living at admission was significantly related to home discharge. Additional insight in other factors that might predict home discharge after geriatric rehabilitation among this specific group of frail older stroke patients, is needed. TRIAL REGISTRATION: ISRCTN ISRCTN62286281. Registered 19-3-2010.

The impact of cardiac arrest on the long-term wellbeing and caregiver burden of family caregivers: a prospective cohort study.

OBJECTIVE: The purpose was to gain insight in the functioning of caregivers of cardiac arrest survivors at 12 months after a cardiac arrest. Secondly, the course of the wellbeing of the caregivers during the first year was studied. Finally, factors that are associated with a higher care burden at 12 months after the cardiac arrest were investigated. SUBJECTS: A total of 195 family caregivers of cardiac arrest survivors were included. MAIN MEASURES: Quality of life (SF-36, EuroQol-VAS), caregiver strain (CSI) and emotional functioning (HADS, IES) were measured at two weeks, three months and one year after the cardiac arrest. Thereby, the caregiver was asked to fill out the cognitive failure questionnaire (CFQ) to evaluate their view on the cognitive status of the patient. RESULTS: Caregiver strain was high in 16 (15%) of the caregivers at 12 months. Anxiety was present in 33 (25%) caregivers and depression in 18 (14%) caregivers at 12 months. The repeated measures MANOVA showed that during the first year the following variables improved significantly: SF-36 domains social and mental health, role physical, role emotional and vitality, caregiver strain, HADS and IES ( P<0.001). At 12 months caregiver strain correlated significantly (explained variance 63%, P=0.03) with caregiver HADS ( P=0.01), EuroQol-VAS ( P=0.02), and the CFQ ( P<0.001), all measured at 12 months after the cardiac arrest. CONCLUSIONS: Overall wellbeing of the caregivers improves during the first year up to normal levels, but caregivers with emotional problems or perceived cognitive problems at 12 months are at risk for developing a higher care burden.

Does the fear avoidance model explain persistent symptoms after traumatic brain injury?

BACKGROUND: A minority of patients with mild traumatic brain injury (mTBI) experience a persistent symptom complex also known as post-concussion syndrome. Explanations for this syndrome are still lacking. OBJECTIVE: To investigate if the fear avoidance model, including catastrophizing thoughts and fear avoidance behaviour, poses a possible biopsychosocial explanation for lingering symptoms and delay in recovery after traumatic brain injury (TBI) with special focus on mTBI. DESIGN: Cross-sectional study. PARTICIPANTS: 48 patients with TBI, of which 31 patients with mTBI, had persistent symptoms (mean time since injury 48.2 months); 92% of the entire sample fulfilled the criteria for post-concussion syndrome. OUTCOME VARIABLES: catastrophizing, fear-avoidance, depression and post-concussion symptoms. RESULTS: High levels of catastrophizing were found in 10% and high levels of fear avoidance behaviour were found in 35%. Catastrophizing, fear avoidance behaviour, depressive symptoms and post-concussion symptoms correlated significantly with each other (p < 0.05). CONCLUSION: The fear-avoidance model proposes a possible explanation for persistent symptoms. Validation and normative data are needed for suitable measures of catastrophizing and fear avoidance of post-concussion symptoms after TBI. Longitudinal prospective cohort studies are needed to establish its causal and explanatory nature.

Perceived Physical Activity Decline as a Mediator in the Relationship Between Pain Catastrophizing, Disability, and Quality of Life in Patients with Painful Diabetic Neuropathy.

BACKGROUND: To fully understand the burden of painful diabetic neuropathy (PDN), we investigated the relationship of pain catastrophizing with disability and quality of life in patients with PDN. Furthermore, we studied the mediating roles of physical activity and/or decline in physical activity. METHODS: This questionnaire-based cross-sectional study included 154 patients with PDN. Linear regression analyses, adjusted for age, gender, pain intensity, and insulin treatment, were performed to assess the association of pain catastrophizing (Pain Catastrophizing Scale [PCS]) with the outcome variables disability (Pain Disability Index [PDI]) and quality of life (Norfolk Quality of Life Questionnaire Diabetic Neuropathy Version [QOL-DN]). The mediating roles of actual physical activity (Physical Activity Rating Scale [PARS]) and perceived Physical Activity Decline (PAD) were assessed using mediation analyses according to Baron and Kenny. RESULTS: This study included 154 patients (62% male). Mean age was 65.7 years (SD = 6.6). PCS (M = 20.3, SD = 13.1) was significantly associated with PDI (M = 32.4, SD = 17.0; R2 = 0.356, P < 0.001), QOL-DN (M = 52.6, SD = 26.1; R2 = 0.437, P < 0.001), and PAD (M = 7.4, SD = 5.7; R2 = 0.087, P = 0.045). PAD acted as a partial mediator in the associations of PCS with PDI and QOL-DN, respectively. There was no association of PCS with PARS. CONCLUSIONS: Pain catastrophizing was associated with increased disability and decreased quality of life in patients with PDN. Also, it was associated with a perceived decline in physical activity, which had a mediating role in the association between catastrophizing and disability and quality of life, respectively. This study emphasizes the role of catastrophic thinking about pain and the experienced loss in daily activities due to PDN.

Content Validity of the Credibility and Expectancy Questionnaire in a Pain Rehabilitation Setting.

BACKGROUND: Content validity, the proper reflection of the concept to be measured, is yet unknown for the Credibility and Expectancy Questionnaire (CEQ). It is frequently used in pain rehabilitation because treatment expectancy is influential on the outcome. OBJECTIVE: To test and improve the content validity of the CEQ in a sample of patients with chronic pain in different phases of their treatment. METHODS: A qualitative observational study design using the Three-Step Test-Interview method was used. Therein, data collection, analyses, and adaptations occur iteratively. RESULTS: Seventeen patients with chronic pain in different stages of treatment participated through convenience sampling from the mother sample of a randomized controlled trial. The main study parameter is content validity, which is defined as (1) interpretations and responses of the participants and (2) the identification of response problems operationalized, and resulting in changes in the CEQ. For patients waiting for treatment, the written instruction of the CEQ allowed different interpretations. After changing the instructions, the CEQ became an easy-to-understand and content-valid questionnaire. For patients who had already undergone treatment, changes regarding time frame and recall period were necessary to overcome interpretation and response problems to the CEQ. DISCUSSION: After small changes, the CEQ appeared to be a content-valid measurement instrument for patients waiting for treatment. However, for patients who had already undergone treatment, the content validity of the CEQ was less, and considerable changes were necessary.

Multidisciplinary Treatment for Adolescents with Chronic Pain and/or Fatigue: Who Will Benefit?

PURPOSE: The aims of this study were, first, to determine the percentage of adolescents with chronic pain/fatigue successfully treated with rehabilitation treatment for chronic pain/fatigue and, second, to identify predictors for a successful rehabilitation treatment. METHODS: Treatment success is scored based on a combination of predefined clinically relevant changes in 4 outcome measures: level of pain/fatigue, school absence, physical functioning, and psychosocial functioning. A forward stepwise logistic regression analysis with treatment success as a dependent variable is performed to identify predictors for successful treatment. RESULTS: A total of 172 adolescents (mean age 16.2 [SD = 2.5]; 85.5% girls) participated. Almost half (49.6%) of the adolescents had a successful treatment. The explained variance for the complete model explaining treatment success was 49% (R2 = 0.487). Patients with a higher level of pain/fatigue and a passive coping style pretreatment improved most, and these factors could thus be indicated as predictors for successful treatment. Also, gender significantly contributed to the prediction, in favor of boys. CONCLUSIONS: Regarding the first aim, using predefined treatment success based on clinically relevant changes, half of the participants had a successful treatment. Concerning the second aim, adolescents with a high level of pain/fatigue and those with a high passive coping style pretreatment have a better ability to change their functioning during treatment. Boys benefit more than girls.

Painful Diabetic Neuropathy Anxiety Rasch-Transformed Questionnaire (PART-Q30(©) ).

The association between painful diabetic neuropathy (PDN) and anxiety has been acknowledged using various anxiety scales capturing various fear entities. It has never been examined whether these generally applied anxiety questionnaires could be pooled to construct one overall anxiety metric. After completion by a cohort of 151 patients with PDN, data obtained from seven generally applied fear scales were stacked (n = 88 items) and subjected to Rasch analyses (pre-PART-Q88) to create the PDN overall Anxiety Questionnaire (PART-Q30(©) ). We subsequently examined the impact of the final constructed PART-Q30(©) on disability and Quality of Life (QoL) using the Rasch-Transformed Pain Disability Index (RT-PDI) and the Norfolk Quality of Life Questionnaire, Diabetic Neuropathy version (RT-Norfolk). The pre-PART-Q88 data did not meet Rasch model's expectations. Through stepwise examination for model fit, disordered thresholds, local dependency and item bias, we succeeded in reducing the data and constructing a 30 items overall anxiety scale (PART-Q30(©) ) that fulfilled all model's expectations, including unidimensionality. An acceptable internal reliability was found (person-separation-index: 0.90). PART-Q30(©) explained 36% of disability and combined with RT-PDI 63% of QoL (assessed with RT-Norfolk).

Disability in Adolescents and Adults Diagnosed With Hypermobility-Related Disorders: A Meta-Analysis.

OBJECTIVE: To (1) establish the association of the most common reported symptoms on disability; and (2) study the effectiveness of treatment on disability in patients with Ehlers-Danlos syndrome-hypermobility type (EDS-HT)/hypermobility syndrome (HMS). DATA SOURCES: An electronic search (Medical Subject Headings and free-text terms) was conducted in bibliographic databases CENTRAL/MEDLINE. STUDY SELECTION: Comparative, cross-sectional, longitudinal cohort studies and (randomized) controlled trials including patients with HMS/EDS-HT aged ≥17 years were considered for inclusion. A class of symptoms was included when 5 publications were available. In regards to treatment (physical, cognitive interventions), only (randomized) controlled trials were considered. Surgical and medicinal interventions were excluded. DATA EXTRACTION: Bias was assessed according to the methodological scoring tools of the Cochrane collaboration. Z-score transformations were applied to classify the extent of disability in comparison with healthy controls and to ensure comparability between studies. DATA SYNTHESIS: Initially, the electronic search yielded 714 publications, and 21 articles remained for analysis after selection. The following symptoms were included for meta-analysis: pain (n=12), fatigue (n=6), and psychological distress (n=7). Pain (r=.64, P=.021), fatigue (r=.91, P=.011), and psychological distress (r=.86, P=.018) had a significant impact on disability. Regarding treatment, a significant pain reduction was achieved by a variety of physical and cognitive approaches. Treatment effectiveness on disability was not established. CONCLUSIONS: Disability can affect patients with HMS/EDS-HT significantly and is highly correlated with both physical and psychological factors. Although evidence is available that physical and psychological treatment modalities can induce significant pain reduction, the evidence regarding disability reduction is lacking.

Study protocol for a multicentre randomized controlled trial on effectiveness of an outpatient multimodal rehabilitation program for adolescents with chronic musculoskeletal pain (2B Active).

BACKGROUND: Chronic musculoskeletal pain (CMP) in adolescents can influence functioning and well-being, and has negative consequences for families and society as well. According to the Fear Avoidance Model, fear of movement and pain catastrophizing can influence the occurrence and maintenance of chronic pain complaints and functional disability. Primary objective is to evaluate the effectiveness of a multimodal rehabilitation program in reducing functional disability for adolescents with CMP compared with care as usual. METHODS/DESIGN: Pragmatic multicentre parallel group randomized controlled trial. Randomization by minimization (ratio 1:1) and treatment allocation will be concealed, computer-generated and performed by an independent organization. After randomization, data collection and researchers remain blinded. Inclusion of 124 adolescents and their parents is intended. This sample size is based on a 25 % difference in group mean on the primary outcome, with α = 5 %, ß = 80 % and expected 15 % loss to follow up. Study population are adolescents (12-21 years) with CMP with an indication for outpatient rehabilitation treatment in the Netherlands. The intervention group receives a Multimodal Rehabilitation Program (MRP), a multidisciplinary outpatient individual rehabilitation program. MRP consists of 2 different treatment approaches: A graded exposure module or a combination module of graded exposure and physical training. Selection of a module depends on the needs of the patient. To both modules a parent module is added. The control group receives care as usual, which is the care currently provided in Dutch rehabilitation centres. Treatment duration varies between 7 and 16 weeks, depending on treatment allocation. Self-reported measurements are at baseline, and at 2, 4, 10 and 12 months after start of treatment. Intention to treat analysis for between group differences on all outcome variables will be performed. Primary outcome is functional disability (Functional Disability Inventory). Secondary outcome variables are fear of pain, catastrophizing, perceived harmfulness, pain intensity, depressive symptoms, and quality of life. Total direct and indirect costs and health related quality of life will be measured. Process evaluation focuses on protocol adherence, patient centeredness and treatment expectations. DISCUSSION: A pragmatic approach was chosen, to ensure that results obtained are most applicable to daily practice. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT02181725 (7 February 2014). Funded by Fonds Nuts Ohra, Stichting Vooruit, and Adelante.

Energy Expenditure during Functional Daily Life Performances in Patients with Fibromyalgia.

OBJECTIVE: The objective of this study was to evaluate whether patients with fibromyalgia FM need more oxygen and more time to complete a walking and stair-climbing task than healthy volunteers and perceive the performance of these tasks as more strenuous. Furthermore, it was evaluated whether a less efficient performance is more pronounced in patients reporting a higher level of fear of movement. METHODS: Thirty patients with FM and 30 matched healthy volunteers completed a 500-meter walking and a stair-climbing task (60 steps) while wearing a mobile gas analyzing unit. Mean and total oxygen consumption and time needed to complete each task were recorded. After both tasks, a Borg score was used to measure perceived exertion. Fear of movement was measured with the Tampa Scale for Kinesiophobia. RESULTS: Patients with FM needed more time to complete the walking and stair-climbing task and reported higher levels of exertion compared to healthy volunteers. However, the total oxygen consumption for performing both tasks was not different. In patients with FM, a higher level of fear of movement was associated with a higher perceived exertion after the walking task. Interestingly, a higher somatic focus is related to a lower mean oxygen consumption needed to perform the stair-climbing task. CONCLUSION: In conclusion, patients with FM perceive a walking and stair-climbing task as more strenuous than healthy controls, even though they walked slower and no differences in total O2 consumption during completion of both tasks were found.

The Musician as (In)Active Athlete?: Exploring the Association Between Physical Activity and Musculoskeletal Complaints in Music Students.

OBJECTIVE: Musicians are often compared to athletes because of the physical exertion required to play music. The aim of this study was to explore the physical activity level of music students and to study its relationship with musculoskeletal complaints. A second goal was to assess associations between physical activity and pain, quality of life, and disability. METHODS: This cross-sectional study among third- and fourth-year music students used an electronic survey including measures for physical activity (SQUASH-Short Questionnaire to Assess Health-enhancing physical activity), musculoskeletal complaints (DMQ-Dutch Musculoskeletal Questionnaire), disability (DASH-Disability Arm, Shoulder, Hand questionnaire) and quality of life (Short Form-12). Students were classified as compliers or non-compliers with moderate- and vigorous-intensity physical activity recommendations. Statistical analysis was done using (non)parametric tests (t-test, Pearson chi-square test, Mann-Whitney U-test) and correlational testing. RESULTS: Participants were 132 students, 63.6% female, with a median age of 23 yrs (range 21.3-25.0). 67% reported musculoskeletal complaints in the past 7 days. Their median physical activity level was 6,390 MET-min/wk, and 62% and 10% of the students accomplished recommendations for moderate-intensity and vigorous-intensity physical activity levels, respectively. No significant differences were found in prevalence of musculoskeletal complaints between students who met moderate- or vigorous-intensity physical activity recommendations and students who did not. Physical activity level was not associated with musculoskeletal complaints (r=0.12, p=0.26). Higher pain intensity was associated with a lower quality of life (r=-0.53 p<0.01) and higher disability (r=0.43, p<0.01). CONCLUSIONS: Music students are mainly involved in light- to moderate-intensity physical activities and rarely in vigorous-intensity activities. No correlation was found between physical activity level in the past months and musculoskeletal complaints in music students.