Hip biomechanics in patients with low back pain, what do we know? A systematic review.

BACKGROUND: Biomechanical alterations in patients with low back pain (LBP), as reduced range of motion or strength, do not appear to be exclusively related to the trunk. Thus, studies have investigated biomechanical changes in the hip, due to the proximity of this joint to the low back region. However, the relationship between hip biomechanical changes in patients with LBP is still controversial and needs to be summarized. Therefore, the aim of this study was to systematically review observational studies that used biomechanical assessments in patients with non-specific LBP. METHODS: The search for observational studies that evaluated hip biomechanical variables (i.e., range of motion, kinematic, strength, and electromyography) in adults with non-specific acute, subacute, and chronic LBP was performed in the PubMed, Embase, Cinahl and Sportdiscus databases on February 22nd, 2024. Four blocks of descriptors were used: 1) type of study, 2) LBP, 3) hip and 4) biomechanical assessment. Two independent assessors selected eligible studies and extracted the following data: author, year of publication, country, study objective, participant characteristics, outcomes, and results. The methodological quality of the studies was assessed using the Epidemiological Appraisal Instrument and classified as low, moderate, and high. Due to the heterogeneity of the biomechanical assessment and, consequently, of the results among eligible studies, a descriptive analysis was performed. RESULTS: The search strategy returned 338 articles of which 54 were included: nine articles evaluating range of motion, 16 evaluating kinematic, four strength, seven electromyography and 18 evaluating more than one outcome. The studies presented moderate and high methodological quality. Patients with LBP, regardless of symptoms, showed a significant reduction in hip range of motion, especially hip internal rotation, reduction in the time to perform functional activities such as sit-to-stance-to-sit, sit-to-stand or walking, greater activation of the hamstrings and gluteus maximus muscles and weakness of the hip abductor and extensor muscles during specific tests and functional activities compared to healthy individuals. CONCLUSION: Patients with LBP present changes in range of motion, task execution, activation, and hip muscle strength when compared to healthy individuals. Therefore, clinicians must pay greater attention to the assessment and management of the hip during the treatment of these patients. SYSTEMATIC REVIEW REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020213599).

Development of a brief core set for knee dysfunction based on the International Classification of Functioning, Disability and Health: assessing construct validity and measurement potential.

BACKGROUND: The comprehensive core set for knee dysfunction was developed to classify the functioning of people with any knee dysfunction. To be used as a clinical instrument to measure the functioning of people with knee dysfunction, the construct validity of the core set still needs to be assessed. The purpose of this study was to analyze the construct validity of the comprehensive core set for knee dysfunction as an instrument to measure functioning. METHODS: A cross-sectional study with 200 participants with knee dysfunction with or without clinical diagnosis of knee pathology, with or without complaint of pain, with or without instability, and/or with or without knee movement restriction of any type. Participants were assessed using the comprehensive core set for knee dysfunction with 25 categories, the subjective form from the International Knee Documentation Committee scale, and measures of self-perceived general health and functioning. The construct validity of the core set was assessed by Rasch analysis, and the external construct validity was assessed by correlation between the score of the brief core set for knee dysfunction with the subjective form from the International Knee Documentation Committee scale, and scores of self-perception of health and functioning. RESULTS: Twelve categories were consistent with a unidimensional construct, with no difference in the response pattern for age, sex, educational level, and time of complaint. These categories were included in the brief core set for knee dysfunction. The mean score of the brief core set was 37 ± 21 points, a value classified as moderate impairment regarding functioning. Correlations with the subjective form from the International Knee Documentation Committee scale and scores of self-perception were adequate (p < 0.01; r > 0.5). CONCLUSION: The brief core set for knee dysfunction, a set with 12 categories, can be used as a clinical instrument to measure and score the functioning of people with knee dysfunction, aged between 18 and 89 years, with adequate construct validity.

Development of a Core Set for Knee Dysfunction Based on the International Classification of Functioning, Disability and Health: A Cross-sectional Study.

OBJECTIVE: To develop an International Classification of Functioning, Disability and Health core set for patients with knee dysfunction. DESIGN: Cross-sectional study. SETTING: The study was conducted at all levels of care (general community, primary care units, rehabilitation clinics/centers, hospital). PARTICIPANTS: Participants (N=388) with knee dysfunction with or without clinical diagnosis of knee pathology, with or without complaint of pain, with or without instability, and/or with or without knee movement restriction of any type. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were assessed using the core sets for acute and postacute musculoskeletal conditions, the subjective form from the International Knee Documentation Committee scale, the self-report of general health and functionality, and the general health and functionality classified by the researcher. To identify the categories that best explain knee dysfunction, linear regression analyses were performed. RESULTS: Twenty-four categories were identified from the 75 core set categories for acute and postacute musculoskeletal conditions. Eleven categories belong to the component body functions, 3 represent body structures, 7 represent activities and participation, and 3 represent environmental factors. CONCLUSIONS: A core set for knee dysfunction that can be used at all levels of health care was proposed, which offers a system for disability assessment related to knee dysfunction, including environmental and social factors. These factors are important for a broad assessment because they include the multiple aspects of functionality, usually not considered in other knee dysfunction assessment instruments. Further analysis of the content and construct validity of the core set is required.

Effectiveness of the Pilates method versus aerobic exercises in the treatment of older adults with chronic low back pain: a randomized controlled trial protocol.

BACKGROUND: Chronic low back pain is potentially disabling for older adults, and exercise is considered the best treatment. The Pilates method and aerobic exercises have been proven to be effective in pain and function improvement in patients with low back pain, but evidence in the treatment of older adults with low back pain is scarce. Therefore, the objective of this study is to investigate the effectiveness of the Pilates method compared to aerobic exercises in the treatment of older adults with chronic nonspecific low back pain. METHODS: This is a randomized controlled trial with blinded assessor, to be held in a physical therapy clinic in Sao Paulo, Brazil. Seventy four patients aged 65 to 85 years with chronic nonspecific pain will be randomized into Pilates Group (n = 37) with exercises based on the Pilates method and Aerobic Group (n = 37) with treadmill aerobic exercise. The primary outcomes will be pain intensity and general disability, assessed eight weeks after randomization. The secondary outcomes will be: pain intensity and general disability, assessed six months after randomization; and global perceived improvement, specific disability, dynamic balance, muscle strength (gluteus maximus, gluteus medius, and lateral hip rotators), and pressure pain threshold, assessed eight weeks and six months after randomization. Therapists and patients will not be blinded. DISCUSSION: This study has the potential to reduce pain and, consequently, improve balance and function of older adults with chronic low back pain with both therapies. However, Pilates may be more effective because the exercises are more targeted to the trunk stabilization muscles. The results of this study may provide valuable information on the effects of Pilates and aerobic exercise in older adults with chronic low back pain and contribute to a better selection of the treatment program according to the patient preference. TRIAL REGISTRATION: ClinicalTrials.gov NCT02729779 , April 6, 2016.

Cost-effectiveness of exercise therapy in the treatment of non-specific neck pain and low back pain: a systematic review with meta-analysis.

OBJECTIVE: To investigate the cost-effectiveness of exercise therapy in the treatment of patients with non-specific neck pain and low back pain. DESIGN: Systematic review of economic evaluations. DATA SOURCES: The search was performed in 5 clinical and 3 economic electronic databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included economic evaluations performed alongside randomised controlled trials. Differences in costs and effects were pooled in a meta-analysis, if possible, and incremental cost-utility ratios (ICUR) were descriptively analysed. RESULTS: Twenty-two studies were included. On average, exercise therapy was associated with lower costs and larger effects for quality-adjusted life-year (QALY) in comparison with usual care for subacute and chronic low back pain from a healthcare perspective (based on ICUR). Exercise therapy had similar costs and effect for QALY in comparison with other interventions for neck pain from a societal perspective, and subacute and chronic low back pain from a healthcare perspective. There was limited or inconsistent evidence on the cost-effectiveness of exercise therapy compared with usual care for neck pain and acute low back pain, other interventions for acute low back pain and different types of exercise therapy for neck pain and low back pain. CONCLUSIONS: Exercise therapy seems to be cost-effective compared with usual care for subacute and chronic low back pain. Exercise therapy was not (more) cost-effective compared with other interventions for neck pain and low back pain. The cost-utility estimates are rather uncertain, indicating that more economic evaluations are needed. REGISTRATION: PROSPERO, CRD42017059025.

Different doses of Pilates-based exercise therapy for chronic low back pain: a randomised controlled trial with economic evaluation.

OBJECTIVES: To evaluate the effectiveness and cost-utility of the addition of different doses of Pilates to an advice for non-specific chronic low back pain (NSCLBP) from a societal perspective. DESIGN: Randomised controlled trial with economic evaluation. SETTING: Physiotherapy clinic in São Paulo, Brazil. PARTICIPANTS: 296 patients with NSCLBP. INTERVENTIONS: All patients received advice and were randomly allocated to four groups (n=74 per group): booklet group (BG), Pilates once a week (Pilates group 1, PG1), Pilates twice a week (Pilates group 2, PG2) and Pilates three times a week (Pilates group 3, PG3). MAIN OUTCOME MEASURES: Primary outcomes were pain and disability at 6-week follow-up. RESULTS: Compared with the BG, all Pilates groups showed significant improvements in pain (PG1, mean difference (MD)=-1.2, 95% CI -2.2 to -0.3; PG2, MD=-2.3, 95% CI -3.2 to -1.4; PG3, MD=-2.1, 95% CI -3.0 to -1.1) and disability (PG1, MD=-1.9, 95% CI -3.6 to -0.1; PG2, MD=-4.7, 95% CI -6.4 to -3.0; PG3, MD=-3.3, 95% CI -5.0 to -1.6). Among the different doses, PG2 showed significant improvements in comparison with PG1 for pain (MD=-1.1, 95% CI -2.0 to -0.1) and disability (MD=-2.8, 95% CI -4.5 to -1.1). The cost-utility analysis showed that PG3 had a 0.78 probability of being cost-effective at a willingness-to-pay of £20 000 per quality-adjusted life-year gained. CONCLUSIONS: Adding two sessions of Pilates exercises to advice provided better outcomes in pain and disability than advice alone for patients with NSCLBP; non-specific elements such as greater attention or expectation might be part of this effect. The cost-utility analysis showed that Pilates three times a week was the preferred option. TRIAL REGISTRATION NUMBER: NCT02241538, Completed.

Muscle Activation During Pilates Exercises in Participants With Chronic Nonspecific Low Back Pain: A Cross-Sectional Case-Control Study.

OBJECTIVE: To determine the amplitude of the electromyographic activity of trunk muscles during Pilates exercises in women with and without chronic low back pain (LBP). DESIGN: Case-control study. SETTING: University physical therapy clinic. PARTICIPANTS: Women (N=60) divided into an LBP group and a control group. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Amplitude of the electromyographic activity (root mean square values) of the gluteus maximus and external oblique muscles collected during 3 Pilates exercises: Shoulder Bridge performed on the mat, and Hip Roll and Breathing performed in equipment. Pain intensity was assessed in the LBP group. RESULTS: The amplitude of the electromyographic activity was similar between groups (P≥.05). For both groups, the amplitude of the gluteus maximus was higher in the Shoulder Bridge exercise compared with the Hip Roll with 2 springs (control group: mean difference [MD]=.18; 95% confidence interval [CI], .05-.41; LBP group: MD=.29; 95% CI, .16-.31) and the Breathing exercise (control group: MD=-.40; 95% CI, -.55 to -.26; LBP group: MD=-.36; 95% CI, -.52 to -.20). The amplitude of the external oblique muscle was higher in the Shoulder Bridge compared with the Hip Roll with 2 springs (control group: MD=.13; 95% CI, .05-.21; LBP group: MD=.18; 95% CI, .03-.33). Pain intensity increased after exercises, but this increase was lower for the mat exercises. CONCLUSIONS: Similar muscle activation between groups was found. The findings suggest that mat exercises caused less pain and a greater difference in the amplitude of muscle activation compared with the equipment-based exercises.

Evaluation of cross-cultural adaptation and measurement properties of breast cancer-specific quality-of-life questionnaires: a systematic review.

PURPOSE: To assess the procedures of translation, cross-cultural adaptation, and measurement properties of breast cancer-specific quality-of-life questionnaires. METHODS: Searches were conducted in the databases MEDLINE, EMBASE, CINAHL, and SciELO using the keywords: "Questionnaires," "Quality of life," and "Breast cancer." The studies were analyzed in terms of methodological quality according to the guidelines for the procedure of cross-cultural adaptation and the quality criteria for measurement properties of questionnaires. RESULTS: We found 24 eligible studies. Most of the articles assessed the translation and measurement properties of the instrument EORTC QLQ-BR23. Description about translation and cross-cultural adaptation was incomplete in 11 studies. Translation and back translation were the most tested phases, and synthesis of the translation was the most omitted phase in the articles. Information on assessing measurement properties was provided incompletely in 23 articles. Internal consistency was the most tested property in all of the eligible articles, but none of them provided information on agreement. Construct validity was adequately tested in only three studies that used the FACT-B and QLQ-BR23. Eight articles provided information on reliability; however, only four found positive classification. Responsiveness was tested in four articles, and ceiling and floor effects were tested in only three articles. None of the instruments showed fully adequate quality. CONCLUSION: There is limited evidence on cross-cultural adaptations and measurement properties; therefore, it is recommended that caution be exercised when using breast cancer-specific quality-of-life questionnaires that have been translated, adapted, and tested.

Örebro Questionnaire: short and long forms of the Brazilian-Portuguese version.

PURPOSE: To translate, cross-culturally adapt and test the measurement properties of the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) short and long versions in Brazilian-Portuguese. METHODS: The ÖMPSQ versions were translated, cross-culturally adapted and pretested in 30 patients with acute and subacute non-specific low back pain. Internal consistency, reproducibility (reliability and agreement), construct validity, and ceiling and floor effects were tested in 100 patients. Construct validity was assessed using the Roland-Morris Disability Questionnaire (RMDQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Numerical Rating Scale. RESULTS: Internal consistency was adequate (ÖMPSQ: Cronbach's alpha = 0.83; ÖMPSQ-short: Cronbach's alpha = 0.72). Reliability was substantial (ÖMPSQ: ICC2,1 0.76; ÖMPSQ-short: 0.78). Standard error of measurement was very good for the ÖMPSQ (5 %) and good for the ÖMPSQ-short (6.7 %); limits of agreement were 13.07 for the ÖMPSQ and 1.37 for the ÖMPSQ-short; and the minimum detectable change was 25.12 for the ÖMPSQ and 15.51 for the ÖMPSQ-short. The ÖMPSQ total score showed a good correlation with the RMDQ (r = 0.73) and the TSK (r = 0.64) and a moderate correlation with pain intensity (current pain: r = 0.36; last 2 weeks: r = 0.37; last episode: r = 0.46). Moreover, ÖMPSQ-short showed a good correlation with RMDQ (r = 0.69) and a moderate correlation with TSK (r = 0.57) and pain (current pain: r = 0.34; last 2 weeks: r = 0.36; last episode: r = 0.54). No ceiling or floor effects were detected in both versions. CONCLUSION: The Brazilian-Portuguese ÖMPSQ and ÖMPSQ-short showed acceptable measurement properties and provide evidence that the Brazilian-Portuguese versions of ÖMPSQ and ÖMPSQ-short are similar to the original versions.

Efficacy of the addition of interferential current to Pilates method in patients with low back pain: a protocol of a randomized controlled trial.

BACKGROUND: Chronic low back pain is one of the four most common diseases in the world with great socioeconomic impact. Supervised exercise therapy is one of the treatments suggested for this condition; however, the recommendation on the best type of exercise is still unclear. The Pilates method of exercise is effective in reducing pain and disability in these patients, as well as the analgesia promoted by interferential current. Currently, the literature lacks information on the efficacy of the association of these two techniques in the short- and medium-term than performing one of the techniques isolated. The objective of this study will be to evaluate the efficacy of adding interferential current to the Pilates method exercises for the treatment of patients with chronic nonspecific low back pain in the short- and medium-term. METHODS/DESIGN: This study will be a randomized controlled trial with two arms and blinded evaluator, conducted at an outpatient Physical Therapy Department in Brazil. Patients with nonspecific chronic low back pain and pain equal to or greater than 3 in the Pain Numerical Rating Scale (0/10) will be randomly assigned to one of two groups: Group with active interferential current + Pilates (n = 74) will be submitted to the active interferential current associated to the modified Pilates exercises, and Group with sham interferential current + Pilates (n = 74) will be submitted to the sham interferential current associated with the modified Pilates exercises during 18 sessions. The outcomes pain intensity, pressure pain threshold, general and specific disability, global perceived effect and kinesiophobia will be evaluated by a blinded assessor at baseline, six weeks and six months after randomization. DISCUSSION: Because of the study design, blinding of the participants and the therapists involved in the study will not be possible. The results of this study could contribute to the process of clinical decision- making for the improvement of pain and disability in participants with nonspecific chronic low back pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT01919268.

Effectiveness of mat Pilates or equipment-based Pilates in patients with chronic non-specific low back pain: a protocol of a randomised controlled trial.

BACKGROUND: Chronic low back pain is an expensive and difficult condition to treat. One of the interventions widely used by physiotherapists in the treatment of chronic non-specific low back pain is exercise therapy based upon the Pilates principles. Pilates exercises can be performed with or without specific equipment. These two types of Pilates exercises have never been compared on a high-quality randomised controlled trial. METHODS/DESIGN: This randomised controlled trial with a blinded assessor will evaluate eighty six patients of both genders with chronic low back pain, aged between 18 and 60 years, from one Brazilian private physiotherapy clinic. The patients will be randomly allocated into two groups: Mat Group will perform the exercises on the ground while the Equipment-based Group will perform the Pilates method exercises on the following equipment: Cadillac, Reformer, Ladder Barrel, and Step Chair. The general and specific disability of the patient, kinesiophobia, pain intensity and global perceived effect will be evaluated by a blinded assessor before randomisation and at six weeks and six months after randomisation. In addition, the expectation of the participants and their confidence with the treatment will be evaluated before randomisation and after the first treatment session, respectively. DISCUSSION: This will be the first study aiming to compare the effectiveness of Mat and Equipment-based Pilates exercises in patients with chronic non-specific low back pain. The results may help health-care professionals in clinical decision-making and could potentially reduce the treatment costs of this condition. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials RBR-7tyg5j.

Is Pilates more effective and cost-effective than aerobic exercise in the treatment of patients with fibromyalgia syndrome? A randomized controlled trial with economic evaluation.

BACKGROUND: The aim of this study was to assess the effectiveness and cost-effectiveness of Pilates versus aerobic exercises in the treatment of patients with fibromyalgia syndrome from a societal perspective. METHODS: This two-arm randomized controlled trial with blinded assessor and economic evaluation included 98 patients diagnosed with fibromyalgia syndrome using the American College of Rheumatology 2010 criteria, aged between 20 and 75 years, and pain intensity ≥3 points in the Pain Numerical Rating Scale. Patients were randomly allocated into the aerobic or Pilates group. Treatment was performed twice a week for 8 weeks. The primary outcome was the impact of fibromyalgia measured 8 weeks after randomization. Cost-effectiveness and cost-utility analyses were conducted for the impact of fibromyalgia and quality-adjusted life-years (QALYs), respectively, with a 12-month time horizon. RESULTS: There was no difference between the groups for the impact of fibromyalgia (MD: 6.5 points; 95% CI: -1.8 to 14.9). The incremental cost-effectiveness ratio showed that 1-point increase in the impact of fibromyalgia was on average associated with a societal cost of £56 for the Pilates group compared to the aerobic group. The cost-utility analysis showed that the Pilates group had a 0.71 probability of being cost-effective at a willingness-to-pay of £30,000 per QALY gained. CONCLUSION: There was no significant difference between groups for the impact of fibromyalgia. Pilates was not cost-effective compared to aerobic exercises for the impact of fibromyalgia. However, Pilates seemed to be the preferred option of treatment considering QALYs, although it depends on the willingness-to-pay threshold. SIGNIFICANCE: Pilates showed to be a safe and effective alternative for the treatment of patients with fibromyalgia syndrome. Pilates presented similar results for the impact of fibromyalgia and superior results for pain relief compared to aerobic exercises, a highly recommended intervention for the treatment of fibromyalgia syndrome. Pilates was not cost-effective compared to aerobic exercises for the impact of fibromyalgia. However, Pilates seemed to be a cost-effective intervention for QALYs, depending on the decision-maker's willingness-to-pay threshold.

Author Response to "The Therapeutic Alliance May Yet Prove Effective".

Author response to the JOSPT Letter to the Editor-in-Chief "The Therapeutic Alliance May Yet Prove Effective" J Orthop Sports Phys Ther 2021;51(10):527-528. doi:10.2519/jospt.2021.0203-R.

Economic evaluations of educational, physical, and psychological treatments for fibromyalgia: a systematic review with meta-analysis.

ABSTRACT: Nonpharmacological interventions are recommended for the treatment of fibromyalgia, but there is a lack of knowledge about the cost-effectiveness of these interventions. The aim of this study was to systematically review economic evaluations of educational, physical, and psychological interventions for the treatment of fibromyalgia. The search was performed in PUBMED, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, PsycINFO, EconLit, National Health Service Economic Evaluation Database, and Health Technology Assessment. Economic evaluations of educational, physical, and psychological interventions for adult patients with fibromyalgia were included. Primary outcomes were healthcare and societal costs, and quality-adjusted life-years, and secondary outcomes were any disease-specific clinical outcome. Costs and effects were pooled in a meta-analysis, when possible. Eleven studies were included, of which 7 compared a psychological intervention with another intervention or usual care/control. Over a 6-month time horizon, healthcare and societal costs of the psychological intervention were significantly lower than usual care (mean difference: $-2087, 95% confidence interval [CI]: -3061 to -1112; mean difference: $-2411, 95% CI: -3582 to -1240, respectively), and healthcare costs were significantly lower for the psychological intervention compared with a pharmacological intervention (mean difference: $-1443, 95% CI: -2165 to -721). Over a 12-month time horizon, healthcare costs for the psychological intervention were significantly lower than for usual care (mean difference: $-538, 95% CI: -917 to -158). Incremental cost-effectiveness ratios for quality-adjusted life-years and impact of fibromyalgia showed that the psychological intervention was cost-effective compared with other interventions and control conditions. There is a need of more economic evaluations conducted alongside randomized controlled trials with interventions recommended for the treatment of fibromyalgia, such as physical exercise.

Analysis of the measurement properties of the Brazilian-Portuguese version of the Tampa Scale for Kinesiophobia-11 in patients with fibromyalgia.

OBJECTIVE: To analyze the measurement properties of the Brazilian-Portuguese version of the Tampa Scale for Kinesiophobia-11 in patients with fibromyalgia. METHODS: Assessment was made at three time points: baseline (n=130) and 15 days (n=54) and eight weeks after baseline (n=51). Data collected at baseline were used to assess internal consistency, criterion and construct validity, and ceiling and floor effects. Data collected at baseline and 15 days after baseline were used to assess reliability and measurement error, and data collected before and after an eight-week exercise-based physical therapy intervention were used to assess interpretability of change scores. RESULTS: The Tampa Scale for Kinesiophobia-11 showed adequate internal consistency (Cronbach's alpha=0.77; alpha if item deleted: 0.74-0.77), substantial reliability (intraclass correlation coefficient2,1=0.85; 95% confidence interval: 0.75, 0.90), good measurement error (standard error of measurement: 2.65 points), and a minimal detectable change (90% confidence) of 6.16 points. For validity, the Tampa Scale for Kinesiophobia-11 showed a positive and good correlation with the original Tampa Scale for Kinesiophobia (r=0.84, p<0.01), positive and moderate correlation with the Pain Catastrophizing Scale (r=0.55, p<0.01), positive and weak correlation with the Numerical Pain Rating Scale (r=0.25, p<0.01), positive and moderate correlation with the Beck Depression Inventory (r=0.39, p<0.01), and no correlation with the Patient-Specific Functional Scale (r=0.11, p=0.23). Kinesiophobia, pain, function, catastrophizing, and depression statistically improved after the eight-week intervention (p<0.01). CONCLUSION: The Tampa Scale for Kinesiophobia-11 is consistent, reliable, and appropriate to assess fear of movement in patients with fibromyalgia in the clinical context. Responsiveness of the Tampa Scale for Kinesiophobia-11 should be tested in future studies.

Comparison between different health state utility instruments in patients with fibromyalgia.

BACKGROUND: Cost-utility analysis uses utility indexes to assess treatment effects. Some discrepancies between different utility indexes instruments are suggested and need to be identified in health conditions not yet investigated. OBJECTIVE: To compare different utility indexes instruments in Brazilian patients with fibromyalgia and identify variables associated with these instruments. METHODS: Impact of fibromyalgia (Fibromyalgia Impact Questionnaire [FIQ]) and utility indexes (Short-Form 6 Dimensions [SF-6D], EuroQol 5 Dimensions [EQ-5D], and EuroQol - Visual Analogue Scale [EQ-VAS]) were assessed in 97 patients with fibromyalgia at baseline, 8-week (after an exercise-based intervention), and 6- and 12-month follow-up. Construct validity and responsiveness of the utility indexes instruments were compared. Multiple regression models were used to verify the variables associated with the utility indexes instruments. RESULTS: Construct validity analysis showed that FIQ presented moderate correlation with the SF-6D, the EQ-5D, and the EQ-VAS (r=-0.43, -0.41, -0.30, respectively, all p < .01). There was a moderate correlation between the SF-6D and the EQ-5D (r = 0.51, p < .001), moderate correlation between the SF-6D and the EQ-VAS (r = 0.41, p < .001), and no correlation between the EQ-VAS and the EQ-5D. The EQ-5D was responsive at the 8-week and 6-month follow-up, the SF-6D was responsive only at 6-month follow-up and the EQ-VAS was not responsive. The FIQ was associated with the EQ-5D and the SF-6D indexes, and symptom duration and depression with the EQ-VAS index. CONCLUSION: The EQ-5D better assessed the clinical change in patients with fibromyalgia. Furthermore, impact of fibromyalgia, symptom duration, and depression seem to be associated with the utility indexes.

Interpretation of trial-based economic evaluations of musculoskeletal physical therapy interventions.

BACKGROUND: As resources for healthcare are scarce, decision-makers increasingly rely on economic evaluations when making reimbursement decisions about new health technologies, such as drugs, procedures, devices, and equipment. Economic evaluations compare the costs and effects of two or more interventions. Musculoskeletal disorders have a high prevalence and result in high levels of disability and high costs worldwide. Because physical therapy interventions are usually the first line of treatment for musculoskeletal disorders, economic evaluations of such interventions are becoming increasingly important for stakeholders in the field of physical therapy, including physical therapists, decision-makers, and reseachers. However, economic evaluations are relatively difficult to interpret for the majority of stakeholders. OBJECTIVE: To support physical therapists, decision-makers, and researchers in the field of physical therapy interpreting trial-based economic evaluations and translating the results of such studies to clinical practice. METHODS: The design, analysis, and interpretation of economic evaluations performed alongside randomized controlled trials are discussed. To further illustrate and explain these concepts, we use a case study assessing the cost-effectiveness of exercise therapy compared to standard advice in patients with musculoskeletal disorders. CONCLUSIONS: Economic evaluations are increasingly being used in healthcare decision-making. Therefore, it is of utmost importance that their design, conduct, and analysis are state-of-the-art and that their interpretation is adequate. This masterclass will help physical therapists, decision-makers, and researchers in the field of physical therapy to critically appraise the quality and results of trial-based economic evaluations and to apply the results of such studies to their own clinical practice and setting.

Education With Therapeutic Alliance Did Not Improve Symptoms in Patients With Chronic Low Back Pain and Low Risk of Poor Prognosis Compared to Education Without Therapeutic Alliance: A Randomized Controlled Trial.

OBJECTIVES: To compare the effectiveness of an education intervention with or without the addition of the therapeutic alliance to no education intervention in patients with nonspecific chronic low back pain (LBP) and low risk of poor prognosis. DESIGN: Randomized controlled trial. Randomization was performed using randomly generated numbers. METHODS: Two hundred twenty-two patients with nonspecific chronic LBP and low risk of poor prognosis from 2 university physical therapy services in Taubaté, Brazil were randomized into 3 groups: education plus therapeutic alliance, education only, and no education. Primary outcomes were pain (measured with the numeric pain-rating scale) and patient-specific disability (measured with the Patient-Specific Functional Scale), assessed 1 month after randomization. The patients, therapists, and assessors were not blinded due to the nature of the intervention and self-reported outcomes. RESULTS: Patients were recruited between November 2015 and February 2017. There was a loss of 17 (7.6%) follow-up assessments at 1 month, 28 (12.6%) at 6 months, and 31 (13.9%) at 12 months after randomization, and intention-to-treat analyses were conducted. There were no significant differences in pain between groups. However, there was a significant improvement in patient-specific disability for the education-plus-therapeutic alliance and education-only groups compared to no education after 1 month (mean difference, -1.41; 95% confidence interval: -2.31, -0.51 and -0.95; 95% confidence interval: -1.85, -0.04, respectively). CONCLUSION: An education intervention did not provide clinically relevant improvements in patient-specific disability and did not influence pain in patients with nonspecific chronic LBP and low risk of poor prognosis. Additionally, there was no difference between interventions with or without emphasis on the therapeutic alliance. J Orthop Sports Phys Ther 2021;51(8):392-400. Epub 7 May 2021. doi:10.2519/jospt.2021.9636.

Different weekly frequencies of Pilates did not accelerate pain improvement in patients with chronic low back pain.

BACKGROUND: Recent evidence recommends Pilates for the treatment of chronic low back pain. However, it is still unknown if different weekly frequencies of Pilates can accelerate the improvement of symptoms in patients with chronic low back pain verified by a daily pain assessment. OBJECTIVE: To analyze whether different weekly frequencies of Pilates can accelerate pain reduction by 30%, 50%, and 100% in patients with non-specific chronic low back pain and the necessary number of weeks to reach these improvements. METHODS: Two hundred and twenty-two patients were randomized into three groups: Pilates group 1 received treatment once a week, Pilates group 2 received treatment twice a week, and Pilates group 3 received treatment three times a week. All groups received Pilates for six weeks. Pain intensity was measured daily before and after each intervention session using the Pain Numerical Rating Scale. The assessor was not blind. RESULTS: The survival analysis showed that all Pilates groups had a pain reduction of 30%, 50%, and 100% at the same speed during treatment. There was no difference between the different weekly frequencies of Pilates for any of the comparisons (p>0.05). After the first week of treatment, 44.6% of the patients in Pilates group 3 showed complete pain improvement, followed by 37.8% of the patients in Pilates group 2 and 29.7% in Pilates group 1. After the last week, 71.6% (Pilates group 1), 77% (Pilates group 2), and 78.4% (Pilates group 3) of the patients reported complete improvement of symptoms. CONCLUSION: Different weekly frequencies of Pilates did not accelerate pain improvement in patients with non-specific chronic low back pain. Registered in Clinical Trials Registry: NCT02241538 (https://clinicaltrials.gov/ct2/show/NCT02241538).

Cross-cultural adaptation of the Pelvic Girdle Questionnaire (PGQ) into Brazilian Portuguese and clinimetric testing of the PGQ and Roland Morris questionnaire in pregnancy pelvic pain.

OBJECTIVE: To translate and cross-culturally adapt the Pelvic Girdle Questionnaire (PGQ) into Brazilian Portuguese and test the measurement properties of the PGQ and the Roland Morris Disability Questionnaire (RMDQ) in women with pelvic pain during pregnancy. METHODS: Thirty pregnant women were included in the assessment of the pre-test of the final version of the PGQ and 100 were included in the assessment of the measurement properties. In the initial assessment, the PGQ, RMDQ, pain numerical rating scale, and WHOQOL-BREF were applied to test the internal consistency and construct validity. In the 48-hour assessment, only the PGQ and RMDQ were applied to test reliability and measurement error; in the reassessment after one month, the PGQ, RMDQ, and global perceived effect scale were applied to evaluate responsiveness. RESULTS: The PGQ showed adequate internal consistency (Cronbach's alpha=0.83), substantial reliability (ICC2,1=0.85), very good measurement error (5%), and good responsiveness (r=-0.62). We also observed good correlation with disability and quality of life in the physical health domain, moderate correlation with pain and quality of life in the psychological domain, and poor correlation with quality of life in the domains social relationships and environment. The RMDQ showed adequate internal consistency (Cronbach's alpha=0.80), substantial reliability (ICC2,1=0.76), good measurement error (9%), moderate responsiveness (r=-0.51), moderate correlation with quality of life in the physical health and psychological domains, and weak correlation with pain and quality of life in the social relationships and environment domains. CONCLUSION: The Brazilian Portuguese version of the PGQ showed superior measurement properties compared to the RMDQ, being a valid, reliable, and responsive instrument for assessing patients with pelvic pain during pregnancy.