Variability in the prevalence of depression among adults with chronic pain: UK Biobank analysis through clinical prediction models.

BACKGROUND: The prevalence of depression among people with chronic pain remains unclear due to the heterogeneity of study samples and definitions of depression. We aimed to identify sources of variation in the prevalence of depression among people with chronic pain and generate clinical prediction models to estimate the probability of depression among individuals with chronic pain. METHODS: Participants were from the UK Biobank. The primary outcome was a "lifetime" history of depression. The model's performance was evaluated using discrimination (optimism-corrected C statistic) and calibration (calibration plot). RESULTS: Analyses included 24,405 patients with chronic pain (mean age 64.1 years). Among participants with chronic widespread pain, the prevalence of having a "lifetime" history of depression was 45.7% and varied (25.0-66.7%) depending on patient characteristics. The final clinical prediction model (optimism-corrected C statistic: 0.66; good calibration on the calibration plot) included age, BMI, smoking status, physical activity, socioeconomic status, gender, history of asthma, history of heart failure, and history of peripheral artery disease. Among participants with chronic regional pain, the prevalence of having a "lifetime" history of depression was 30.2% and varied (21.4-70.6%) depending on patient characteristics. The final clinical prediction model (optimism-corrected C statistic: 0.65; good calibration on the calibration plot) included age, gender, nature of pain, smoking status, regular opioid use, history of asthma, pain location that bothers you most, and BMI. CONCLUSIONS: There was substantial variability in the prevalence of depression among patients with chronic pain. Clinically relevant factors were selected to develop prediction models. Clinicians can use these models to assess patients' treatment needs. These predictors are convenient to collect during daily practice, making it easy for busy clinicians to use them.

Outcome Heterogeneity in Prehabilitation Trials-Are We Comparing Apples and Oranges?

INTRODUCTION: Over the last decade, the number of prehabilitation randomised controlled trials (RCTs) has increased significantly. Therefore, this review aimed to describe the outcomes reported in prehabilitation RCTs in patients undergoing cancer surgery. METHODS: A search was conducted in Embase, Allied and Complementary Medicine Database, The Cochrane Library, PsycINFO, MEDLINE, and Cumulated Index to Nursing and Allied Health Literature from inception to July 2021. We included RCTs evaluating the effectiveness of preoperative exercise, nutrition, and psychological interventions on postoperative complications and length of hospital stay in adult oncology patients who underwent thoracic and gastrointestinal cancer surgery. The verbatim outcomes reported in each article were extracted, and each outcome was assessed to determine whether it was defined and measured using a validated tool. Verbatim outcomes were grouped into standardized outcomes and categorized into domains. The quality of outcome reporting in each identified article was assessed using the Harman tool (score range 0-6, where 0 indicated the poorest quality). RESULTS: A total of 74 RCTs were included, from which 601 verbatim outcomes were extracted. Only 110 (18.3%) of the verbatim outcomes were defined and 270 (44.9%) were labeled as either "primary" or "secondary" outcomes. Verbatim outcomes were categorized into 119 standardized outcomes and assigned into one of five domains (patient-reported outcomes, surgical outcomes, physical/functional outcomes, disease activity, and intervention delivery). Surgical outcomes were the most common outcomes reported (n = 71 trials, 95.9%). The overall quality of the reported outcomes was poor across trials (median score: 2.0 [IQR = 0.00-3.75]). CONCLUSIONS: Prehabilitation RCTs display considerable heterogeneity in outcome reporting, and low outcome reporting quality. The development of standardized core outcome sets may help improve article quality and enhance the clinical utility of prehabilitation following cancer surgery.

Clinical guidelines are silent on the recommendation of physical activity and exercise therapy for low back pain: A systematic review.

OBJECTIVES: To synthesise and evaluate the quality of the recommendations for exercise therapy and physical activity from guidelines for the prevention and/or management of low back pain. DESIGN: Systematic review. METHODS: Included clinical practice guidelines for the management of low back pain published between 2014 and 2022 and searched in 9 databases until September 2022. The quality of evidence was evaluated with the Appraisal of Guidelines, Research and Evaluation tool (AGREE-II instrument). RESULTS: After screening 3448 studies, 18 clinical practice guidelines were included in this review. Only five (27 %) guidelines were judged as having a satisfactory quality of evidence (i.e., rigour of development and applicability), and 13 (72 %) of guidelines are discussed and rated as critical. Regarding physical activity, no guidelines provided recommendations for the primary prevention of low back pain or incorporated adequate physical activity aspects considering type, dosage, frequency, and intensity. For exercises, all (100 %) guidelines recommended at least one type of supervised exercise in the management of low back pain, and 16 (88 %) provided an overall recommendation for people to stay active. CONCLUSIONS: Guidelines offer minimal or, sometimes, no detail regarding physical activity or specific exercise regimens for the management and prevention of low back pain. When some guidance is provided, the recommendations typically lack specificity concerning the type, intensity, duration, and frequency of exercise and, in many cases, they represent a combination of scarce available evidence and stakeholder perspectives.

Effectiveness of an eHealth-Delivered Program to Empower People With Musculoskeletal Pain in Rural Australia: A Randomized Controlled Trial.

OBJECTIVE: Our objective was to evaluate the effectiveness of a three-month physiotherapist-delivered eHealth physical activity program compared with usual care to improve function in adults with low back pain or knee osteoarthritis in rural Australia. METHODS: This was a parallel, two-group, pragmatic, superiority, randomized controlled trial involving three- and six-month posttreatment follow-ups. There was a total of 156 adults with chronic nonspecific low back pain (n = 97) or knee osteoarthritis (n = 59) from rural Australia. The intervention involved an eHealth physical activity and an exercise program that included five to eight teleconsultations with a physiotherapist (primary time point three months) or usual care (eg, general practitioner, physiotherapy, and pain medication). The primary outcome was the Patient-Specific Functional Scale (0-30), with a three-point difference between groups being considered the minimum clinically important difference. RESULTS: Participants receiving the eHealth intervention (n = 78) reported significantly greater and clinically worthwhile improvements in function (mean between-group difference 3.6; 95% confidence interval [CI] 1.3-5.9) compared to participants receiving usual care (n = 78). Small but statistically significantly greater improvements in disability (7.2 of 100; 95% CI 2.1-12.3) and quality of life (4.5 of 100; 95% CI 0.0-9.0) also favored the eHealth group. No clinical or statistical differences between groups were found for the secondary outcomes of pain, coping skills, and physical activity levels. CONCLUSION: A physiotherapist-delivered eHealth intervention is effective and provides clinically meaningful improvements in function compared to usual care for people with musculoskeletal pain in rural communities. These findings highlight the potential for eHealth-based programs to improve access to evidence-based exercise interventions for people with musculoskeletal pain in rural communities.

A review of patient recruitment in randomised controlled trials of preoperative exercise.

BACKGROUND: Randomised controlled trials (RCTs) are considered the gold standard design to determine the effectiveness of an intervention, as the only method of decreasing section bias and minimising random error. However, participant recruitment to randomised controlled trials is a major challenge, with many trials failing to recruit the targeted sample size accordingly to the planned protocol. Thus, the aim of this review is to detail the recruitment challenges of preoperative exercise clinical trials. METHODS: A comprehensive search was performed on MEDLINE, Embase, The Cochrane Library, CINAHL, AMED and PsycINFO from inception to July 2021. Randomised controlled trials investigating the effectiveness of preoperative exercise on postoperative complication and/or length of hospital stay in adult cancer patients were included. Main outcomes included recruitment rate, retention rate, number of days needed to screen and recruit one patient and trial recruitment duration. Descriptive statistics were used to summarise outcomes of interest. RESULTS: A total of 27 trials were identified, including 3656 patients screened (N = 21) and 1414 randomised (median recruitment rate (interquartile range) = 53.6% (25.2%-67.6%), N = 21). The sample size of the included trials ranged from 19 to 270 (median = 48.0; interquartile range = 40.0-85.0) and the duration of trial recruitment ranged from 3 to 50 months (median = 19.0 months; interquartile range = 10.5-34.0). Overall, a median of 3.6 days was needed to screen one patient, whereas 13.7 days were needed to randomise one participant. Over the trials duration, the median dropout rate was 7.9%. Variations in recruitment outcomes were observed across trials of different cancer types but were not statistically significant. CONCLUSION: The recruitment of participants to preoperative exercise randomised controlled trials is challenging, but patient retention appears to be less of a problem. Future trials investigating the effectiveness of a preoperative exercise programme following cancer surgery should consider the time taken to recruit patients. Strategies associated with improved recruitment should be investigated in future studies.

Barriers and facilitators to reducing paracetamol use in low back pain: A qualitative study.

BACKGROUND: Paracetamol is widely used for low back pain (LBP), but research questions its efficacy and safety. Patient education booklets have been explored for promoting deprescribing, but barriers and facilitators specific to LBP deprescribing remain unexamined. OBJECTIVE: To identify contextual factors facilitating and obstructing successful deprescribing of paracetamol for LBP after receiving an educational booklet. STUDY DESIGN: This study is part of an uncontrolled cohort feasibility study (CEASE NOW) in the community, recruiting from Musculoskeletal Australia and painaustralia. PATIENT SAMPLE: Twenty-four participants with acute, sub-acute, or chronic LBP, self-reporting paracetamol consumption, were included. METHODS: Thematic content analysis was used to analyze qualitative data on barriers and facilitators. Data were categorized by deprescribing outcomes: i) successful deprescribing, ii) attempted but failed, or iii) no attempt. Semi-structured telephone interviews were conducted within one week after each participant completed the one-month follow-up. RESULTS: Successful deprescribing was facilitated by supportive healthcare professionals, willingness, high self-efficacy, fear of future illness, and diverse strategies for deprescribing plans. Barriers included unsupportive healthcare professionals and fear of flare-ups. Participants not attempting deprescribing believed it unnecessary, perceived it as effortful, unquestioningly trusted healthcare professionals, and lacked risk awareness. CONCLUSIONS: Support from healthcare professionals, patient willingness, perceived necessity, risk awareness, effort, and varied strategies influence deprescribing outcomes for LBP patients using paracetamol. Addressing these factors is crucial when designing interventions to promote safe and effective deprescribing in LBP management.

The impact of aggregate positive lifestyle behaviors on low back pain resilience and care seeking.

BACKGROUND CONTEXT: Low back pain (LBP) is a global issue, and the high associated costs are mainly attributed to a small proportion of people with LBP who seek care. Importantly, the impact of aggregate positive lifestyle behaviors on LBP resilience and care seeking is not known. PURPOSE: This study aimed to evaluate the relationship between positive lifestyle behaviors and LBP resilience. STUDY DESIGN: This study was a prospective longitudinal cohort study. PATIENT SAMPLE: Data was collected as part of the AUstralian Twin BACK Study (AUTBACK). Participants who reported a lifetime previous history of LBP at baseline were included in this analysis (n = 340). OUTCOME MEASURES: The outcomes of interest were the number of weeks without activity limiting LBP and total number of days of healthcare usage, health practitioner care, self-management care, and medication intake. METHODS: A lifestyle behavior score was built using variables of body mass index (BMI), physical activity, smoking status, and sleep quality. Negative binomial regression analyses were used to assess the relationship between the positive lifestyle behavior score and the count outcomes of number of weeks without activity limiting LBP and number of days participants used care. RESULTS: After adjusting for covariates, no association was found between participants' positive lifestyle behavior score and their number of weeks without activity limiting LBP (IRR: 1.02, 95% CI 1.00-1.05). There was a statistically significant relationship between higher positive lifestyle behavior scores and fewer number of days of participants' total healthcare usage (IRR:0.69, 95% CI 0.56-0.84), healthcare practitioner visits (IRR:0.62, 95% CI 0.45-0.84), use of self-management strategies (IRR:0.74, 95% CI 0.60-0.91), and use of pain medication (IRR:0.55, 95% CI 0.44-0.68). CONCLUSION: People who adopt optimal lifestyle behaviors, such as engaging in adequate physical activity, achieving optimal quality sleep, maintaining an ideal BMI, and not smoking, may not experience less time suffering from activity limiting LBP, but are less likely to use healthcare and pain medication for their LBP.

Effect of Braces on Performance in the Context of Chronic Ankle Instability.

Ankle braces are commonly recommended for prevention of ankle sprains, especially secondary sprains, rehabilitation, and return to normal activity or sport after injury. One common resistance to use is the feeling that braces will impede functional performance. For people with chronic ankle instability, the limited research indicates that the use of semirigid, lace-up, or soft-shell braces will not affect, and in some cases, may enhance performance. Activities that could be enhanced are jumping, hopping, and dynamic balance.

The impact of different intensities and domains of physical activity on analgesic use and activity limitation in people with low back pain: A prospective cohort study with a one-year followup.

BACKGROUND: Analgesics are the most common form of managing low back pain (LBP). No previous study has examined which domains and intensities of physical activity are most beneficial in reducing the frequency of analgesic use for LBP and its related activity limitation. METHODS: This cohort study forms part of the AUstralian Twin low BACK pain study, investigating the impact of physical activity on LBP. Information on demographics, LBP and health-related factors, including physical activity, were collected at baseline. Data on the total counts of analgesic use and activity limitation for LBP were collected weekly for one-year. Negative binomial regression models were conducted separately for each type of physical activity. Results were presented as incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: From an initial sample of 366 participants, 86 participants reported counts of analgesic use and 140 recorded counts of activity limitation across the follow-up period. The negative binomial regression models for analgesic use counts indicated that engagement in moderate-vigorous physical activity was protective for use of analgesics (IRR 0.97, 95% CI 0.96-0.99), while physical workload was associated with greater use (IRR 1.02, 95% CI 1.01-1.05). No other significant relationships were observed for the other measures of physical activity. For activity limitation counts, engagement in leisure activity was associated with less counts of activity limitation (IRR 0.94, 95% CI 0.81-0.99), while greater amounts of sedentary time was associated with higher counts (IRR 1.04, 95% CI 1.01-1.09). No other significant relationships were observed for the other measures of physical activity. CONCLUSIONS: Our findings highlight the potential importance of supporting engagement in moderate-vigorous and leisure physical activity as well as minimizing sedentary time and physical workload to reduce the risk of activity limitation and the need for analgesic use in people with LBP. SIGNIFICANCE: We examined which domains and intensities of physical activity are most beneficial in reducing the frequency of analgesic use for low back pain and its related activity limitation. Engaging in moderate-vigorous and leisure physical activity as well as minimizing sedentary time and physical workload has the potential to reduce the risk of activity limitation and the need for analgesic use in people with low back pain.

The effect of ankle supports on lower limb biomechanics during functional tasks: A systematic review with meta-analysis.

OBJECTIVES: To systematically review the literature on the effects of ankle supports on lower extremity biomechanics during functional tasks. DESIGN: Systematic review with meta-analysis. METHODS: Eight electronic databases were searched from inception to July 2019. Studies of biomechanical outcomes during functional tasks that used a within-participant (repeated measures) design were included. Two independent reviewers screened studies, extracted data, assessed the methodological quality of the included studies and rated the quality of evidence. Meta-analysis was performed and reported as standardised mean differences and 95% confidence intervals. RESULTS: A total of 8350 studies were identified in the electronic search and 42 studies involving a total of 761 participants were included in the review (21 studies included for qualitative reporting and 21 studies in the meta-analysis). Most individual studies and the meta-analyses demonstrated no effect of ankle supports on ground reaction force or ankle inversion angle. However, there was high quality evidence that ankle taping decreased plantarflexion angle at initial contact during landing from a height (P = 0.0009, standerdised mean differences = 0.72, 95% confidence intervals = 1.15, 0.03, I 2 = 3%). The effect of ankle supports on transverse plane ankle biomechanics has not been adequately investigated. CONCLUSIONS: Ankle taping only decreased plantarflexion angle at initial contact during landing from a jump. Ankle supports did not affect inversion angle or forces in linear and multiplanar tasks. There was insufficient evidence on the effect of ankle supports on ankle transverse plane biomechanics.

Individualised, targeted step count intervention following gastrointestinal cancer surgery: The Fit-4-Home randomised clinical trial.

BACKGROUND: To determine the effectiveness of an individualised, daily targeted step count intervention and usual care compared with usual care alone on improving surgical and patient reported outcomes. METHODS: The Fit-4-Home trial was a pragmatic, randomised controlled trial conducted from April 2019 to February 2021. Patients undergoing elective surgery for liver, stomach or pancreatic cancer in two Australian hospitals were recruited. Participants were randomly allocated to receive an individualised, targeted step count intervention and usual care (intervention) or usual care alone (control). A wearable activity tracker was provided to the intervention group to monitor their daily step count target. Primary outcome was the length of stay in the gastrointestinal ward. Secondary outcomes included postoperative complication rates, discharge destination, quality of life, physical activity, pain, fatigue, distress and hospital re-admission within 30 days. Outcome measures were compared between groups using non-parametric statistics. RESULTS: Of the 96 patients recruited, 47 were randomised to the intervention group and 49 were randomised to the control group. The median (interquartile) length of stay in the ward was 7 days (5.0-13.0) in the intervention group and 7 days (5.0- 12.0) in the control group (p = 0.330). Fatigue scores were worse in the intervention group when compared to control (p = 0.018). No other differences between groups were observed. CONCLUSIONS: An individualised, daily targeted step count intervention and usual care did not confer additional benefits in reducing the length of stay in the ward compared to usual care alone for patients undergoing gastrointestinal cancer surgery. TRIAL REGISTRATION: Registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12619000194167).

Association of chronic musculoskeletal pain with mortality among UK adults: A population-based cohort study with mediation analysis.

BACKGROUND: We aimed to quantify the association between chronic musculoskeletal pain and all-cause mortality, and to investigate the extent to which this association is mediated by physical activity, smoking status, alcohol consumption, and opioid use. METHODS: For this population-based cohort study, we used data from UK Biobank, UK between baseline visit (2006-2010) to 18th December 2020. We assessed the associations between chronic musculoskeletal pain and all-cause mortality using a Cox proportional hazards model. We performed causal mediation analyses to examine the proportion of the association between chronic musculoskeletal pain and all-cause mortality. FINDINGS: Of the 384,367 included participants, a total of 187,269 participants reported chronic musculoskeletal pain. Higher number of pain sites was associated with increased risk of all-cause mortality compared to having no pain (e.g., four sites vs no site of pain, Hazard Ratio [HR] 1.46, 95% Confidence Interval [CI] 1.35 to 1.57). The multiple mediator analyses showed that the mediating proportions of all four mediators ranged from 53.4% to 122.6%: among participants with two or more pain sites, the effect estimate reduced substantially, for example, HR reduced from 1.25 (95% CI: 1.21 to 1.30; two pain sites) to 1.07 (95% CI: 1.01 to 1.11; two pain sites). INTERPRETATION: We found that higher number of pain sites was associated with increased risk of all-cause mortality compared to having no pain, and at least half of the association of chronic musculoskeletal pain with increased all-cause mortality may be accounted for by four mediators. FUNDING: Twins Research Australia.

Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression.

BACKGROUND: Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA. METHODS: The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression. RESULTS: In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively. CONCLUSION: Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.

Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses.

BACKGROUNDS: There is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery. METHODS: A search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO2), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (VE/VCO2), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible. RESULTS: Fifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO2 was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26-3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49-2.45). Preoperative AT and VE/VCO2 also demonstrated some positive trends. None of the included studies reported a negative trend. CONCLUSIONS: This systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO2, and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.

Association of Lumbar Spine Radiographic Changes With Severity of Back Pain-Related Disability Among Middle-aged, Community-Dwelling Women.

Importance: Previous studies, using mostly cross-sectional data, provide conflicting evidence of an association between lumbar spine radiographic changes and the severity of back pain-related disability. Such conflicting evidence may be associated with widely unnecessary diagnostic imaging of the lumbar spine. Objective: To examine both cross-sectional and longitudinal associations between lumbar spine radiographic changes and the severity of back pain-related disability among middle-aged, community-dwelling women. Design, Setting, and Participants: This population-based prospective cohort study used data from the Chingford 1000 Women Study. Analyses included data collected from year 6 (1994-1996; physical activity was measured), year 9 (1997-1999; treated as baseline), and year 15 (2003-2005), with a total length of follow-up for longitudinal analyses of 6 years. Data were analyzed from April 17 to November 3, 2020. Exposures: Primary exposure was lumbar spine radiographic changes, defined using the Kellgren-Lawrence (K-L) grade. Secondary exposures were defined using presence of osteophytes and disc space narrowing. The composite score combined the number of lumbar spine segments with definite changes detected on radiographic images (ie, radiographic changes) (K-L grade ≥2, which means at least definite osteophyte and possible narrowing of disc space are present; osteophyte and disc space narrowing grade ≥1, which means at least mild or definite changes are present). Main Outcomes and Measures: Self-reported back pain-related disability measured in years 9 and 15 assessed by the St Thomas disability questionnaire. Results: Among 650 women (mean [SD] age, 61.3 [5.9] years) in cross-sectional analyses and 443 women (mean [SD] age, 60.6 [6.0] years) in longitudinal analyses, there was no evidence to support an association between higher number of lumbar segments with radiographic changes (K-L grade, osteophytes, and disc space narrowing) and more severe back pain-related disability (eg, cross-sectional analyses using the K-L grade; 1 segment vs 0 segment: adjusted odds ratio, 1.22 [95% CI, 0.76-1.96]). No interactions were found of an association between lumbar spine radiographic changes and the severity of back pain-specific disability with age, body mass index, or smoking status. Conclusions and Relevance: In this cohort of middle-aged, community-dwelling women, there was no evidence to support an association between a higher number of lumbar segments with radiographic changes (K-L grade, osteophytes, and disc space narrowing) and more severe back pain-related disability cross-sectionally or over time. These findings provide further evidence against routinely using diagnostic imaging of the lumbar spine.

Feasibility and acceptability of a preoperative exercise program for patients undergoing major cancer surgery: results from a pilot randomized controlled trial.

OBJECTIVE: To establish the feasibility and acceptability of a preoperative exercise program, and to obtain pilot data on the likely difference in key surgical outcomes to inform the sample size calculation for a full-scale trial. DESIGN: Pilot randomized controlled trial. SETTING: Royal Prince Alfred Hospital, Sydney, Australia. SUBJECTS: We included patients undergoing elective pelvic exenteration or cytoreductive surgery aged 18 to 80 years, who presented to the participating gastrointestinal surgeon at least 2 weeks prior to surgery. Patients presenting cognitive impairment, co-morbidity preventing participation in exercise, inadequate English language, currently participating in an exercise program or unable to attend the exercise program sessions were excluded. METHODS: Participants were randomized to a 2-6 weeks preoperative, face-to-face, individualised exercise program or to usual care. Feasibility was assessed with consent rates to the study, and for the intervention group, retention and adherence rates to the preoperative exercise program. Acceptability of the exercise program was assessed with a semi-structured questionnaire exploring the advice received and the amount, duration and intensity of the exercise program. In addition, postoperative complication rates (Clavien-Dindo), length of hospital stay and self-reported measures of health-related quality of life (SF-36v2) were collected at baseline, day before surgery and in-hospital up to discharge from hospital. RESULTS: Of 122 patients screened, 26 (21%) were eligible and 22 (85%) accepted to participate in the trial and were randomized to the intervention (11; 50%) or control group (11; 50%). The median age of the include participants was 63 years. Adherence to the preoperative exercise sessions was 92.7%, with all participants either satisfied (33%) or extremely satisfied (67%) with the overall design of the preoperative exercise program. No significant differences in outcomes were found between groups. CONCLUSIONS: The results of our pilot trial demonstrate that a preoperative exercise program is feasible and acceptable to patients undergoing major abdominal cancer surgery. There is an urgent need for a definite trial investigating the effectiveness of a preoperative exercise program on postoperative outcomes in patients undergoing major abdominal cancer surgery. This could potentially reduce postoperative complication rates, length of hospital stay and subsequently overall health care costs. TRIAL REGISTRATION: ACTRN12617001129370. Registered on August 1, 2017, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373396&showOriginal=true&isReview=true.

Comparative Efficacy and Safety of Conservative Care for Pregnancy-Related Low Back Pain: A Systematic Review and Network Meta-analysis.

OBJECTIVE: More than one-half of pregnant women experience pregnancy-related low back pain (LBP). Pregnancy-related LBP greatly affects activities of daily life, and although many interventions have been proposed, the optimal treatment for pregnancy-related LBP remains unclear. The purpose of this study was to compare conservative care strategies on their efficacy and safety for women with pregnancy-related LBP through systematic review with pairwise meta-analysis and network meta-analysis. METHODS: MEDLINE, Embase, the Cochrane Library, AMED, CINAHL, PEDro, PsycINFO, and ClinicalTrials.gov were searched from inception to November 2019. Randomized controlled trials and observational controlled studies were included without restriction to language, sample size, or duration of follow-up. Two independent investigators extracted the data and assessed the risk of bias. The quality of evidence was evaluated through Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Twenty-three studies were included in the qualitative synthesis (18 randomized controlled trials were included in the network meta-analysis). For women with LBP during pregnancy, progressive muscle relaxation therapy (mean difference = -3.96; 95% CI = -7.19 to -0.74; moderate-quality evidence) and Kinesio Taping (mean difference = -3.71; 95% CI = -6.55 to -0.87; low-quality evidence) reduced pain intensity (Visual Analog Scale, range = 0 to 10) compared with placebo. Moderate-quality evidence suggested that transcutaneous electrical nerve stimulation improved physical function (mean difference = -6.33; 95% CI = -10.61 to -2.05; Roland Morris Disability Questionnaire, range = 0-24) compared with placebo. CONCLUSION: For patients with LBP during pregnancy, progressive muscle relaxation therapy and Kinesio Taping may help to decrease pain, and transcutaneous electrical nerve stimulation may improve physical function. IMPACT: This review helps fill the gap in evidence regarding optimal treatment for pregnancy-related LBP. LAY SUMMARY: If you have LBP during pregnancy, your physical therapist has evidence to support the use of progressive muscle relaxation therapy and Kinesio Taping to help decrease pain and the use of transcutaneous electrical nerve stimulation to help improve physical function.

Are people in the bush really physically active? A systematic review and meta-analysis of physical activity and sedentary behaviour in rural Australians populations.

BACKGROUND: Physical inactivity is a major risk factor for non-communicable disease and premature mortality. People who live in rural settings are usually regarded as more physically active than those living in urban areas, however, direct comparisons between these populations are scarce. We aimed to summarise the prevalence of physical inactivity and sedentary behaviour in rural settings in Australia, compared to urban counterparts. METHODS: We searched six databases (AMED, Embase, Medline; CINAHL, SPORTDiscus; and RURAL) and identified 28 observational studies that investigated the levels of physical inactivity and/or sedentary behaviour in adults aged 18 years and over in rural Australia. Random effects meta-analysis was used to generate pooled prevalence estimates. RESULTS: Physical inactivity was four percentage points (95% confidence interval (CI) = 0.4 to 8) higher in rural populations compared to urban populations. There was a one percentage point (95% CI = -3 to 5) prevalence difference of physical activity in the rural populations. Rural populations reported on average 7.8 hours of sedentary time per day (95% CI = 5 to 10) and the prevalence of high levels of sedentary behaviour (≥to 8 hours per day) was 7% (95% CI = -8 to -7) greater in urban areas compared to rural areas. CONCLUSIONS: People living in rural areas are just as physically inactive as people who live in urban areas. Our findings challenge the popular views that rural lifestyles result in people engaging more frequently in physical activity. Public health campaigns promoting physical activity in rural settings are just as necessary as in urban settings.

Preliminary evidence for physical activity following pelvic exenteration: a pilot longitudinal cohort study.

BACKGROUND: The physical activity (PA) level of patients undergoing major cancer surgery remains unclear. This pilot study aimed to: (i) Compare preoperative PA level between patients undergoing major cancer surgery and the general population; (ii) describe PA trajectories following major cancer surgery; (iii) Compare objective versus subjective PA measures in patients undergoing major cancer surgery; and (iv) Investigate the association between preoperative PA level and postoperative outcomes. METHODS: Patients undergoing pelvic exenteration between September/2016 and September/2017 were included and followed at preoperative, 6-weeks and 6-months postoperative. PA was measured using the International Physical Activity Questionnaire Short-Form and McRoberts activity monitor. Analyses were performed using SPSS. RESULTS: This pilot study included 16 patients. When compared to the general population, patients undergoing major cancer surgery presented a reduced preoperative PA level. PA levels decreased at 6 weeks but returned to preoperative levels at 6 months postoperative. Objective and subjective measures of PA were comparable, with some variables presenting strong correlations. A higher preoperative level PA was associated with an absence of postoperative complications and better quality of life outcomes. CONCLUSIONS: Patients undergoing major cancer surgery demonstrated lower PA levels when compared to the general population. PA trajectories decreased at 6 weeks postoperative, returning to preoperative levels within 6-months. In this cohort, it seems that higher preoperative PA level may improve postoperative surgical outcomes; however, this preliminary evidence should be confirmed in a larger cohort.

Return to self-reported physical activity level after an event of acute low back pain.

BACKGROUND: Regular physical activity participation is known to promote better mobility and coordination. Although previous research has established that lack of physical activity participation may increase the risk of developing low back pain, the role of physical activity as a predictor of recovery among symptomatic individuals remains unclear. OBJECTIVE: To evaluate whether: (i) the level of physical activity participation before an acute episode of low back pain predicts recovery within 12 months following the acute pain episode (i.e. index episode); and (ii) participants return to their pre-pain level of physical activity participation 12 months from the index episode. DESIGN: This study used longitudinal data from the TRIGGERS case-crossover study. SETTING: This study was conducted through over-the-phone interviews to participants that presented to 300 primary care clinics with a new episode of acute low back pain. PARTICIPANTS: This study included 999 consecutive patients, aged 18 years or older. Follow-up assessment was completed at 12 months following the index episode. METHODS: This is a cohort study where consecutive patients, aged 18 years or older, that presented with a new episode of acute low back pain were recruited between October 2011 and November 2012. MAIN OUTCOME MEASUREMENTS: Self-reported level of physical activity participation. RESULTS: A total of 830 participants completed the study. When comparing participants who reported pain at 12 months follow-up with those without pain, all participants reported similar levels of physical activity participation one week before (p = 0.449), one week after (p = 0.812) and 12 months after the index episode (p = 0.233). The level of physical activity participation before the index episode was not a reliable predictor of presence of pain at either 3 or 12 months follow-up (OR 0.99; 95% CI 0.993 to 1.003; p = 0.523 and OR 1; 95% CI 0.992 to 1.008; p = 0.923, respectively). CONCLUSION: Physical activity participation did not predict recovery from the pain episode. Also all participants returned to their pre-pain level of physical activity participation after 12 months.