Effects of Inpatient Rehabilitation in Leg Lymphedema: A Naturalistic Prospective Cohort Study With Intra-individual Control of Effects.

OBJECTIVE: To quantify therapy-attributable effects of a comprehensive inpatient rehabilitation program for lower limb lymphedema (LLL) and to compare the levels of health-related quality of life (HRQL) to population-based norms. DESIGN: Naturalistic prospective cohort study with intra-individual control of effects. SETTING: Rehabilitation hospital. PARTICIPANTS: Patients with LLL (N=67; 46 women). INTERVENTIONS: Comprehensive, multidisciplinary inpatient rehabilitation with 45-60 hours of therapy. MAIN OUTCOME MEASURES: Short Form 36 (SF-36) for HRQL, lymphedema-specific Freiburg Quality of Life Assessment for lymphatic disorders, Short Version (FLQA-lk), knee-specific Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), and Symptom Checklist-90Standard (SCL-90S). Observed pre/post rehabilitation effects were individually corrected by subtracting the home waiting-time effects and expressed as standardized effect sizes (ESs) and standardized response means (SRMs). Score differences to norms were quantified by standardized mean differences (SMDs). RESULTS: Participants were on average aged 60.5 years, not yet obese, and had 3 comorbidities (n=67). The greatest improvement was in HRQL on the FLQA-lk with ES=0.767/SRM=0.718, followed by improvements in pain and function with ES/SRM=0.430-0.495 on the SF-36, FLQA-lk, and KOS-ADL (all P<.001). Vitality, mental health, emotional well-being, and interpersonal sensitivity improved most by ES/SRM=0.341-0.456 on all 4 measures (all P≤.003). Post rehabilitation scores were significantly higher than population norms on SF-36 bodily pain (SMD=1.140), vitality (SMD=0.886), mental health (SMD=0.815), and general health (SMD=0.444) (all P<.001), and comparable on the other scales. CONCLUSIONS: Those affected by LLL stages II and III benefited substantially from the intervention, attaining equal or higher levels of HRQL than expected compared with the general population norms. Multidisciplinary, inpatient rehabilitation should be recommended for LLL management.

[Low Back Pain - Value of Prevention and Physiotherapy?] / Rückenschmerzen.

Low Back Pain - Value of Prevention and Physiotherapy? Abstract. Physiotherapy plays a central role in the prevention and treatment of lumbar back pain. There is no clear evidence in science on the effectiveness of individual preventive measures; however, movement and active training as central elements are indispensable here. In the treatment of lumbar back pain, however, the picture is clear: while passive measures such as heat or cold applications as well as ultrasound and electrotherapy should no longer be used alone due to the lack of evidence, the combination of active exercises and patient education shows promising success. If these are supplemented by sporadically applied manual therapy methods, the result is an evidence-based management of both acute and chronic lumbar back pain. One example of a successful implementation of current evidence for the treatment of back pain is GLA:D®, which is also in use in Switzerland since 2021.

Comprehensiveness and validity of a multidimensional assessment in patients with chronic low back pain: a prospective cohort study.

BACKGROUND: Chronic low back pain is a multidimensional syndrome affecting physical activity and function, health-related quality of life and employment status. The aim of the study was to quantify the cross-sectional and longitudinal validity of single measurement scales in specific construct domains and to examine how they combine to build a comprehensive outcome, covering the complex construct of chronic low back pain before and after a standardized interdisciplinary pain program. METHODS: This prospective cohort study assessed 177 patients using the Short Form 36 (SF-36), the Multidimensional Pain Inventory (MPI), the Symptom Checklist-90-Revised (SCL-90-R), the Oswestry Disability Index (ODI), and 2 functional performance tests, the Back Performance Scale (BPS) and the 6-Minute Walking Distance (6MWD). The comprehensiveness and overlap of the constructs used were quantified cross-sectionally and longitudinally by bivariate correlations, exploratory factor analysis, and effect sizes. RESULTS: The mean age of the participants was 48.0 years (+/- 12.7); 59.3% were female. Correlations of baseline scores ranged from r = - 0.01 (BPS with MPI Life control) to r = 0.76 (SF-36 Mental health with MPI Negative mood). SF-36 Physical functioning correlated highest with the functional performance tests (r = 0.58 BPS, 0.67 6MWD) and ODI (0.56). Correlations of change scores (difference of follow-up - baseline score) were consistent but weaker. Factor analysis revealed 2 factors: "psychosocial" and "pain & function" (totally explained variance 44.0-60.9%). Psychosocial factors loaded strongest (up to 0.89 SCL-90-R) on the first factor, covering 2/3 of the explained variance. Pain and function (ing) loaded more strongly on the second factor (up to 0.81 SF-36 Physical functioning at follow-up). All scales showed improvements, with effect sizes ranging from 0.16-0.67. CONCLUSIONS: Our results confirm previous findings that the chronic low back pain syndrome is highly multifactorial and comprises many more dimensions of health and quality of life than merely back-related functioning. A comprehensive outcome measurement should include the predominant psychosocial domain and a broad spectrum of measurement constructs in order to assess the full complexity of the chronic low back syndrome. Convergence and divergence of the scales capture the overlapping contents and nuances within the constructs.

Translation, cross-cultural adaptation and reliability of the German version of the migraine disability assessment (MIDAS) questionnaire.

BACKGROUND: The Migraine Disability Assessment (MIDAS) is a brief questionnaire and measures headache-related disability. This study aimed to translate and cross-culturally adapt the original English version of the MIDAS to German and to test its reliability. METHODS: The standardized translation process followed international guidelines. The pre-final version was tested for clarity and comprehensibility by 34 headache sufferers. Test-retest reliability of the final version was quantified by 36 headache patients completing the MIDAS twice with an interval of 48 h. Reliability was determined by intraclass correlation coefficients and internal consistency by Cronbach's α. RESULTS: All steps of the translation process were followed, documented and approved by the developer of the MIDAS. The expert committee discussed in detail the complex phrasing of the questions that refer to one to another, especially exclusion of headache-days from one item to the next. The German version contains more active verb sentences and prefers the perfect to the imperfect tense. The MIDAS scales intraclass correlation coefficients ranged from 0.884 to 0.994 and was 0.991 (95% CI: 0.982-0.995) for the MIDAS total score. Cronbach's α for the MIDAS as a whole was 0.69 at test and 0.67 at retest. CONCLUSIONS: The translation process was challenged by the comprehensibility of the questionnaire. The German version of the MIDAS is a highly reliable instrument for assessing headache related disability with moderate internal consistency. Provided validity testing of the German MIDAS is successful, it can be recommended for use in clinical practice as well as in research.

Quadriceps performance under activation of foot dorsal extension in healthy volunteers: an interventional cohort study.

BACKGROUND: The m. quadriceps femoris is the strongest muscle in the human body and plays an important role in sports, activities of daily living and independence. Two older studies showed increased electromyographic (EMG) activity of the quadriceps when the dorsal extensors of the foot were pre-activated. The aim was to physiologically replicate this finding by EMG and to verify it functionally by single leg hop. METHODS: EMG activity (root mean square, RMS) was tested on the leg press at the isometric load of the individual 12-repetition-maximum (12RM) weight (on average 79.7 kg) at 45° and 90° knee flexion. Single leg hop distance was measured between the tests. Intra-individual changes between with and without dorsal foot extension were quantified and compared by standardized response means (SRM). RESULTS: Thirty-five healthy subjects between 21 and 57 years were included. The m. vastus medialis was activated on average to an RMS of 32.4 µV without and 53.7 µV with dorsal foot extension (SRM = 1.39, p < 0.001) at 45° knee flexion and an RMS of 124.9 µV versus 152.8 µV (SRM = 1.08, p < 0.001) at 90°. The corresponding data for the rectus femoris were 9.4 µV versus 18.9 µV (SRM = 0.71, p < 0.001) at 45° and 77.8 µV versus 135.3 µV (SRM = 0.89, p < 0.001) at 90°. Mean single leg hop distance was 169.8 cm without versus 178.9 cm with dorsal foot extension (SRM = 1.09, p < 0.001). CONCLUSIONS: Pre-activation of dorsal foot extensors significantly increased EMG activity in the m. quadriceps femoris and single leg hop distance. It can therefore be used to improve functional quadriceps muscle performance and knee joint stability in training and rehabilitation.

Effects of inpatient rehabilitation in hip and knee osteoarthritis: a naturalistic prospective cohort study with intraindividual control of effects.

OBJECTIVES: To quantify pain, function, and health-related quality of life in comparison with normative data, and to quantify intervention effects. DESIGN: Naturalistic cohort study without a control group. Correction of the effects observed during the intervention by those observed during waiting time prior to the intervention. SETTING: Inpatient rehabilitation clinic. PARTICIPANTS: Patients with hip (n=88) and knee (n=164) osteoarthritis. INTERVENTION: Comprehensive, multidisciplinary inpatient rehabilitation lasting 3 weeks. MAIN OUTCOME MEASURES: Medical Outcomes Study 36-Item Short-Form Health Survey and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: Four or more comorbid conditions had 45.3% of the hip and 51.8% of the knee patients on entry to and discharge from the clinic. On entry, physical health and some dimensions of psychosocial health were significantly diminished compared with population norms. At discharge, hip osteoarthritis had improved by a corrected effect size of .20 to .47 in pain, .04 to .39 in function, and -.04 to .32 in psychosocial health. Knee osteoarthritis showed a corrected effect size of .43 to .62 in pain, .19 to .51 in function, and .19 to .30 in psychosocial health. All but 1 effect in WOMAC pain and WOMAC function were higher than the minimal clinically important differences. CONCLUSIONS: Hip and knee osteoarthritis patients admitted to the inpatient intervention were affected by a substantial burden of disease and comorbidities. Inpatient rehabilitation resulted in small to moderate, statistically significant, and clinically important improvements in pain, function, and psychosocial health.

Association of the sense of coherence with physical and psychosocial health in the rehabilitation of osteoarthritis of the hip and knee: a prospective cohort study.

BACKGROUND: According to Antonovsky's salutogenic concept, a strong sense of coherence is associated with physical and psychological health. The goal of this study was to analyze the association of Antonovsky's sense of coherence with physical and psychosocial health components in patients with hip and knee osteoarthritis before and after in- and outpatient rehabilitation. METHODS: Prospective cohort study with 335 patients, 136 (41%) with hip and 199 (59%) with knee osteoarthritis. The outcome was measured by Short Form-36 (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Sense of Coherence (SOC-13). Baseline scores of the SF-36 and WOMAC scales and the observed effect sizes after rehabilitation were correlated with the baseline SOC-13. These correlations of the SF-36 scales were compared to the Factor Score Coefficients for the Mental Component Summary of SF-36, which quantify the factor load on the psychosocial dimension. Predictive impact of the baseline SOC-13 for the SF-36 and WOMAC scales (baseline scores and effect sizes) was then determined by multivariate linear regression controlled for possible confounders. RESULTS: At baseline, the SOC-13 correlated with the WOMAC scores between r = 0.18 (stiffness) and r = 0.25 (pain) and with the SF-36 scores between r = 0.10 (physical functioning) and r = 0.53 (mental health). The correlation of these SF-36 correlation coefficients to the Factor Score Coefficient of the SF-36 Mental Component Summary was r = 0.95. The correlations for the effect sizes (baseline → discharge) with the baseline SOC-13 global score were all negative and varied between r = 0.00 (physical functioning) and r = -0.19 (social functioning). In the multivariate linear regression model, the explained variance of the SF-36 scores by the baseline SOC-13 increased continuously from physical to psychosocial health dimensions (from 12.9% to 29.8%). This gradient was consistently observed for both the baseline scores and the effect sizes. The results of the WOMAC were consistent with the physical health scales of SF-36. CONCLUSIONS: The sense of coherence was associated with psychosocial health dimensions but hardly with physical health. The higher the load of a scale on the psychosocial dimension the higher was its correlation to the sense of coherence. This is in contrast to the idea of Antonovsky who predicted high associations with both mental and physical health.

Relationship between subjectively-rated and objectively-tested physical function across six different medical diagnoses.

OBJECTIVE: To quantify and compare associations and relationships between self-rated and tested assessments of mainly mobility-related physical function in different diagnoses. DESIGN: Six longitudinal cohort studies before and after inpatient rehabilitation. PATIENTS: Patients with whiplash-associated disorder (n = 71), low back pain (n = 121), fibromyalgia (n = 84), lipoedema (n = 27), lymphoedema (n = 78), and post-acute coronary syndrome (n = 64). METHODS: Physical function was measured with the self-rated Short-Form 36 Physical functioning (SF-36 PF) and with the tested 6-Min Walk Distance (6MWD) and assessed by correlation coefficients. Across the 6 cohorts, the relationship between the 2 scores was compared using the ratio between them. RESULTS: The correlations between the 2 scores were mostly moderate to strong at baseline (up to r = 0.791), and weak to moderate for the changes to follow-up (up to r = 0.408). The ratios SF-36 PF to 6MWD were 1.143-1.590 at baseline and 0.930-3.310 for the changes, and depended on pain and mental health. CONCLUSION: Moderate to strong cross-sectional and moderate to weak longitudinal correlations were found between the 6MWD and the SF-36 PF. Pain and mental health should be considered when interpreting physical function. For a comprehensive assessment in clinical practice and research, the combination of self-rated and tested physical function measures is recommended.

[Validation and reliability testing of the "Athlete Fear Avoidance Questionnaire (AFAQ)"]. / Validierung und Reliabilitätsprüfung des "Athlete Fear Avoidance Questionnaire (AFAQ)".

BACKGROUND: Sports injuries may have severe implications for an athlete's career. Psychological factors play an important role on an athlete's journey from the injury to the return to competitive sports. These factors are often insufficiently evaluated, which may lead to prolonged downtime. The Athlete Fear Avoidance Questionnaire (AFAQ) may be used to measure fear avoidance patterns in injured athletes. There is no validated German version of the questionnaire at this time. OBJECTIVE: This study aims to evaluate the test-retest reliability, internal consistency and construct validity of the transculturally translated German version of the AFAQ (AFAQ_D) in injured athletes. METHOD: The German version of the AFAQ_D was translated using the TRAPD model. Construct validity was evaluated with correlations to the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale for Kinesiophobia (TSK). Internal consistency was calculated using Cronbach's Alpha, while the interclass coefficient was used to calculate test-retest reliability. RESULTS: This study included 64 athletes aged 16 to 36 years (Ø 23.15 years, ♀ 17%, ♂ 83%) after a variety of injuries. The AFAQ_D yielded good reliability values with Crohnbach's Alpha being 0.76 (95%CI; 0.67-0.84) in the first measurement and 0.82 (95%CI; 0.76-0.88) in the second measurement, and the interclass coefficient being 0.798 (95%CI; 0.674-0.876). Regarding validity, a moderate correlation was found between the AFAQ_D and the TSK (r=0.57, p<0.01), and a weak and non-significant correlation was found between the AFAQ_D and the FABQ (r=0.13, p=0.31). CONCLUSION: By and large, the German version of the AFAQ is a valid and reliable questionnaire to evaluate fear avoidance as well as the psychological readiness of athletes after an injury. Correlations with TSK and FABQ are roughly comparable with the original study.

Responsiveness of the cervical Northern American Spine Society questionnaire (NASS) and the Short Form 36 (SF-36) in chronic whiplash.

OBJECTIVE: To determine and compare the sensitivity to change of the condition-specific cervical Northern American Spine Society (NASS) and the generic Short Form 36 (SF-36). DESIGN: Prospective cohort study. SUBJECTS: One hundred and seventy five patients after whiplash injury. INTERVENTIONS: Four-week inpatient interdisciplinary pain management programme. MAIN MEASURES, ANALYSIS: Responsiveness of the NASS and the SF-36 was quantified by effect size and standardized response mean and compared within the same construct by the modified Jacknife test. Ability to detect improvement was compared using sensitivities determined from receiver operating characteristics curves. RESULTS: In pain, the NASS was comparable responsive to the SF-36 at the one-month follow-up (n = 175): effect sizes: 0.62 (NASS) versus 0.61 (SF-36), P = 0.914. The NASS was less responsive than the SF-36 in function: 0.23 versus 0.63, P < 0.001 and in pain+function: 0.35 versus 0.58 (P = 0.001). These relationships remained consistent using standardized response means, at the six-month follow-up (n = 103), and in the comparison of the sensitivities. Sensitivities at one month, pain: 70% (NASS) versus 62% (SF-36), P = 0.234; function: 65% versus 80%, P = 0.002; pain+function: 68% versus 78%, P = 0.035. The six-month data were similar. CONCLUSIONS: The generic SF-36 was more responsive in function and equally responsive in pain when compared to the condition-specific NASS. The SF-36 can be recommended as a responsive instrument for measurement of pain and function in chronic whiplash syndrome.

Catastrophizing as a prognostic factor for pain and physical function in the multidisciplinary rehabilitation of fibromyalgia and low back pain.

BACKGROUND: Quantitative data on longitudinal associations between catastrophizing and pain or physical function are patchy. The study aimed to quantify the prognostic value of catastrophizing for pain and function in fibromyalgia and low back pain before and after rehabilitation. METHODS: The associations of state and change on the Multidimensional Pain Inventory (MPI) Pain severity scale, the Short Form 36 (SF-36) Physical functioning scale and the Six-Minute Walking Distance (6MWD) with the Coping Strategies Questionnaire (CSQ) Catastrophizing scale were quantified by multiple regression modelling to adjust for confounders. RESULTS: Sex- and age-matched cohorts (n = 71 each) were compared. Pain and catastrophizing were worse in fibromyalgia than in low back pain, whereas the function levels were comparable. Baseline catastrophizing predicted pain change by adjusted correlations of 0.552 (fibromyalgia) and 0.450 (low back pain), self-rated function by 0.403 and 0.308, and the 6MWD by 0.270 and - 0.072. The change in catastrophizing was associated to the change in pain by 0.440 (fibromyalgia) and 0.614 (low back pain), self-rated function by 0.122 and 0.465, and the 6MWD by 0186 and 0.162. CONCLUSIONS: Catastrophizing (pain-related worrying) was a potential prognostic factor, especially for pain and somewhat less for self-rated physical function but it was only weakly predictive for the walking distance in both conditions, independently of potential confounders, such as sex, age, baseline severity and others. Reduction of maladaptive coping should be integrated into the management of chronic pain. SIGNIFICANCE: Our study showed surprisingly high associations between state and change in catastrophizing to pain relief and functional improvement in chronic pain patients. This is supported by clinical experience and research data, even if the construct and measurement of catastrophizing is under debate. Our findings and those of literature point to more pessimistic self-rating of pain and catastrophizing in fibromyalgia when compared to other conditions. This might obscure positive effects on pain and function achieved by adaptive coping in fibromyalgia.

Substrate and product complexes reveal mechanisms of Hedgehog acylation by HHAT.

Hedgehog proteins govern crucial developmental steps in animals and drive certain human cancers. Before they can function as signaling molecules, Hedgehog precursor proteins must undergo amino-terminal palmitoylation by Hedgehog acyltransferase (HHAT). We present cryo-electron microscopy structures of human HHAT in complex with its palmitoyl-coenzyme A substrate and of a product complex with a palmitoylated Hedgehog peptide at resolutions of 2.7 and 3.2 angstroms, respectively. The structures reveal how HHAT overcomes the challenges of bringing together substrates that have different physiochemical properties from opposite sides of the endoplasmic reticulum membrane within a membrane-embedded active site for catalysis. These principles are relevant to related enzymes that catalyze the acylation of Wnt and of the appetite-stimulating hormone ghrelin. The structural and mechanistic insights may advance the development of inhibitors for cancer.

Common and Contrasting Characteristics of the Chronic Soft-Tissue Pain Conditions Fibromyalgia and Lipedema.

OBJECTIVE: To examine the common and specific characteristics of fibromyalgia and lipedema, two chronic soft-tissue pain syndromes without curative therapy options. METHODS: Diseases' characteristics were compared using the findings of extensive literature and the empiric data from two cohorts, both fulfilling standardized diagnostic criteria. Outcome was measured by various socio-demographics, the generic Short Form 36 (SF-36), the Fibromyalgia Severity Questionnaire (FSQ), and the 6-minute walk distance (6MWD). Empiric SF-36 data were compared to specific population-based norms and between the diagnostic groups, using standardized mean differences (SMD). RESULTS: Female participants with fibromyalgia (n = 77) and lipedema (n = 112) showed comparable education levels and living situations. Lipedema cases were, on average, 3.9 years younger and BMI 6.3kg/m2 more obese. Women with fibromyalgia smoked more, did less sport, had more comorbidities, and worked less. Compared to the norms, health in fibromyalgia was worse than expected by SMD = -1.60 to -2.35 and in lipedema by -0.44 to -0.82 on the SF-36. The score differences between the two conditions ranged from SMD = -0.96 to -1.34 (all p < 0.001) on the SF-36 and the FSQ. For the inpatients (n = 77 fibromyalgia, n = 38 lipedema), the 6MWD was comparable (SMD = -0.09, p = 0.640). These findings were consistent with detailed data from the literature reviewed. DISCUSSION: Fibromyalgia and lipedema share characteristics of clinical phenomenology and comorbid conditions. Disease perception is more pronounced in fibromyalgia than in lipedema, especially in social and role dysfunction, whereas the walking distance was similar for both syndromes. This difference may be explicable by limited coping skills in fibromyalgia.

Extended overview of the longitudinal pain-depression association: A comparison of six cohorts treated for specific chronic pain conditions.

BACKGROUND: The aim was to quantify and to compare the associations between longitudinal changes in pain and depression in different chronic pain conditions. METHODS: Data were retrieved from 6 observational cohort studies. From baseline to the 6-month follow-up, the score changes on the Short Form (36) Health Survey (SF-36) bodily pain (pain) and the SF-36 mental health (depression) scales (0=worst, 100=best) were quantified, using partial correlations obtained by multiple regression. Adjustment was performed by age, living alone/with partner, education level, number of comorbidities, baseline pain and baseline depression. RESULTS: Stronger associations were found between changes in levels of pain and depression for neck pain after whiplash (n = 103, mean baseline pain=21.4, mean baseline depression=52.5, adjusted correlation r = 0.515), knee osteoarthritis (n = 177, 25.4, 64.2, r = 0.502), low back pain (n = 134, 19.0, 49.4, r = 0.495), and fibromyalgia (n = 125, 16.8, 43.2, r = 0.467) than for lower limb lipedema (n = 68, 40.2, 62.6, r = 0.452) and shoulder arthroplasty (n = 153, 35.0, 76.4, r = 0.292). Those correlations were somewhat correlated to baseline pain (rank r=-0.429) and baseline depression (rank r=-0.314). LIMITATIONS: The construct of the full range of depressive symptoms is not explicitly covered by the SF-36. CONCLUSIONS: Moderate associations between changes in pain and depression levels were demonstrated across 5 of 6 different chronic pain conditions. The worse the pain and depression scores at baseline, the stronger those associations tended to be. Both findings indicate a certain dose-response relationship - an important characteristic of causal interference. Relieving pain by treatment may lead to the relief of depression and vice versa.

Comparison of short- and mid-term outcomes of Italian- and German-speaking patients after an interdisciplinary pain management programme in Switzerland: A prospective cohort study.

OBJECTIVE: To quantify and compare the course of health-related quality of life of immigrant native Italian-speaking and German-speaking patients before and after an interdisciplinary pain programme. DESIGN: Prospective cohort study with 1-12 month follow-up. SUBJECTS: Fibromyalgia, generalized widespread pain, and chronic non-specific back pain patients (Italian-speaking n = 96, German-speaking n = 199). METHODS: Score changes measured with the Short Form 36 (SF-36) were compared with multivariate analysis using standardized mean differences (SMD), adjusted for sex, education and the baseline score. RESULTS: At baseline, health of the Italian-speaking patients was worse than for the German-speaking patients. Adjusted SMDs showed significantly better improvements in the German group compared with the Italian group: SF-36 Physical functioning SMD = 0.54 (at discharge) and 0.49 (at 12 months), General health SMD = 0.71 and 0.44, Vitality SMD = 0.43 and 0.48 in one sample. In the other sample, the corresponding SMDs were 0.06 (discharge), 0.50 (3 months) and 0.47 (6 months) for Bodily pain. CONCLUSION: State of health was better and health improvements were greater in German-speaking patients compared with Italian-speaking patients. Patients with a migration background may have special needs in therapeutic management, and addressing these might enhance the positive outcome in the short- and mid-term.

Multidimensional minimal clinically important differences in knee osteoarthritis after comprehensive rehabilitation: a prospective evaluation from the Bad Zurzach Osteoarthritis Study.

OBJECTIVE: To determine minimal clinically important differences (MCIDs) for improvement and worsening in various health dimensions in knee osteoarthritis under conservative therapy. METHODS: Health, symptoms and function were assessed by the generic Short Form 36 and the condition-specific Western Ontario and McMaster Universities Osteoarthritis Index in n=190 patients with knee osteoarthritis before and after comprehensive rehabilitation intervention (3-month follow-up). By means of construct-specific transition questions, MCIDs were defined as the difference between the 'slightly better/worse' and the 'almost equal' transition response categories according to the 'mean change method'. The bivariate MCIDs were adjusted for sex, age and baseline score to obtain adjusted MCIDs by multivariate linear regression. They were further standardised as (baseline) effect sizes (ESs), standardised response means (SRMs) and standardised mean differences (SMDs) and compared with the minimal detectable change with 95% confidence (MDC95). RESULTS: Multivariate, adjusted MCIDs for improvement ranged from 2.89 to 16.24 score points (scale 0-100), corresponding to ES=0.14 to 0.63, SRM=0.17 to 0.61 and SMD=0.18 to 0.72. The matching results for worsening were -5.80 to -12.68 score points, ES=-0.30 to -0.56, SRM=-0.35 to -0.52 and SMD=-0.35 to -0.58. Almost all MCIDs were larger than the corresponding MDC95s. CONCLUSIONS: This study presents MCIDs quantified according to different methods over a comprehensive range of health dimensions. In most health dimensions, multivariate adjustment led to higher symmetry between the MCID levels of improvement and worsening. MCIDs expressed as standardised effect sizes (ES, SRM, SMD) and adjusted by potential confounders facilitate generalisation to the results of other studies.

Effectiveness of subgroup-specific pain rehabilitation: a randomized controlled trial in patients with chronic back pain.

BACKGROUND: Prospective classification of patients with nonspecific chronic back pain into homogeneous subgroups might be an important objective in order to tailor interventions and improve treatment outcomes. AIM: This study investigated the effect of a subgroup-specific pain rehabilitation program based on the Multidimensional Pain Inventory (MPI) Classification System compared to standard care. DESIGN: Single blinded, parallel group, pragmatic randomized controlled trial. SETTING: Inpatient subjects of a rehabilitation clinic. POPULATION: A total of 139 patients with chronic back pain. METHODS: Patients in both the experimental group and control group received during their 4-week in-house stay at the rehabilitation clinic on average four daily sessions of therapy. The patients in the experimental group received specific interventions, which were tailored to their subgroup classification profile. The patients in the control group participated in state-of-the-art care. The primary outcome was self-reported disability measured at 1, 3 and 12 months after randomization with the Oswestry Disability Index (ODI). Secondary outcomes were pain intensity, examiner-reported disability, anxiety and depression, catastrophizing, self-efficacy and global perceived effect. RESULTS: Groups were comparable under demographic and clinical characteristics. No significant differences between the experimental group and the control group for any of the outcomes and follow-up times were found in the intention-to-treat analysis. Compared to the 8-10 points considered as minimal clinically important difference for the ODI, effects within groups were small, e.g. the experimental group improved by 2.2 points at 1-month follow-up, 3.7 points at 3 months and 5.3 points at 12 months. CONCLUSIONS: This study failed to demonstrate that a subgroup-specific program was more effective than standard care. CLINICAL REHABILITATION IMPACT: Since the subgroup-specific interventions were equally effective as standard pain rehabilitation, subgroup classification and tailoring interventions may be an alternative in clinical care.

Interdisciplinary rehabilitation after whiplash injury: An observational prospective 5 years outcome study.

Whiplash injury associated disorders (WAD) cause high costs for public health care. Neck pain is number 16 on the global prevalence lists for the 50 most common sequelae. It is of importance to obtain long-term data on disability and working capacity outcomes after rehabilitation. Long-term prospective data of the outcome course of whiplash are sparse. The aim of this study was to quantify improvements of pain, function/role performance, vitality, and working capacity 5 years after whiplash injury and to compare the state of health to normative values at 5 years after rehabilitation.In this naturalistic, observational, prospective cohort study, 115 patients were assessed 5 years (60 months) after a multidisciplinary rehabilitation program. The assessment set consisted of the Short Form 36 (SF-36), parts of the North American Spine Society's cervical spine assessment questionnaire (NASS) and the coping strategies questionnaire (CSQ). The effects were quantified by effect size (ES) and standardized response mean (SRM). Score differences over the course were tested by the Wilcoxon-Mann-Whitney U test for significance.Comparing data between entry and 60 months after rehabilitation 8 of 15 parameters improved with large ES/SRM. Outcome between 6 and 60 months showed small to moderate ES/SRM. Working capacity increased from 0 at entry to rehabilitation to 21 h/wk at 6 months and to 30 h/wk at 60 months follow-up.After large improvements in health and working capacity in the mid-term, further important improvements were observed in the long-term course. It can be hypothesized that part of those can be attributed to the interventions during inpatient rehabilitation, for example, due to better coping strategies.

Health and quality of life in patients with medication overuse headache syndrome after standardized inpatient rehabilitation: A cross-sectional pilot study.

The aim of this pilot study was to determine health-related quality of life (HRQoL) in patients with history of medication overuse headache (MOH) after detoxification and a headache-specific inpatient rehabilitation program and to receive necessary information for future prospective studies.HRQoL and headache-related disability were cross-sectionally measured by Short Form 36 (SF-36), Hospital Anxiety and Depression Scale (HADS), Migraine Disability Score (MIDAS), Coping Strategies Questionnaire (CSQ), and Symptom Checklist 90 revised (SCL-90-R). SF-36, HADS, and SCL-90-R data were compared to German population norms, stratified by age, sex, and comorbidities.Fifty-one patients (72.5% females, mean age 47.3 years) were included with an average headache duration of 25.3 years. Moderate to high levels of headache were reported on the MIDAS VAS at 6.51 (range 0-10); SF-36 bodily pain was 40.3 (norm = 59.0, P < .001, 100 = best). Impaired functioning averaged at 78.4 (100 = no impairment) on the MIDAS. In contrast, SF-36 physical functioning was comparable to the norm (mean: 78.4, norm = 81.8, P = .63). All other SF-36 scales were significantly lower than expected from the norm (all P < .001). The scales depression, anxiety, obsessive-compulsive, and interpersonal sensitivity were significantly affected, whereas the levels of SCL-90-R schizophrenia nuclear and schizotypia were not lower than the norm. Coping with pain was moderate.This pilot study is the first that presents a comprehensive and simultaneously specific assessment of health and quality of life of MOH patients after detoxification and inpatient rehabilitation. Moderate to high levels of pain and self-reported disability owing to headache were observed, whereas physical function on the SF-36 was not different from the expected level of the norm. Mental health was substantially affected in several dimensions, which had been described to reduce the ability to cope with pain. MOH patients seem to have high expectations of functionality, low symptomatology, and intact well-being.