Nociceptive, neuropathic, or nociplastic low back pain? The low back pain phenotyping (BACPAP) consortium's international and multidisciplinary consensus recommendations.

The potential to classify low back pain as being characterised by dominant nociceptive, neuropathic, or nociplastic mechanisms is a clinically relevant issue. Preliminary evidence suggests that these low back pain phenotypes might respond differently to treatments; however, more research must be done before making specific recommendations. Accordingly, the low back pain phenotyping (BACPAP) consortium was established as a group of 36 clinicians and researchers from 13 countries (five continents) and 29 institutions, to apply a modified Nominal Group Technique methodology to develop international and multidisciplinary consensus recommendations to provide guidance for identifying the dominant pain phenotype in patients with low back pain, and potentially adapt pain management strategies. The BACPAP consortium's recommendations are also intended to provide direction for future clinical research by building on the established clinical criteria for neuropathic and nociplastic pain. The BACPAP consortium's consensus recommendations are a necessary early step in the process to determine if personalised pain medicine based on pain phenotypes is feasible for low back pain management. Therefore, these recommendations are not ready to be implemented in clinical practice until additional evidence is generated that is specific to these low back pain phenotypes.

The Impact of Exercising on Pelvic Symptom Severity, Pelvic Floor Muscle Strength, and Diastasis Recti Abdominis After Pregnancy: A Longitudinal Prospective Cohort Study.

OBJECTIVE: The objective of this study was to evaluate whether early postpartum exercise is associated with changes in pelvic symptom severity, pelvic floor muscle strength, and diastasis recti abdominis (DRA) from 3 to 12 months postpartum. METHODS: In this prospective cohort study, 504 participants with and without pelvic symptoms (pelvic girdle pain, stress urinary incontinence, vaginal heaviness) were followed. At 3, 6, 9, and 12 months postpartum, we assessed pelvic symptoms, exercise behavior (by questionnaires), pelvic floor muscle strength (by vaginal palpation), and DRA (by caliper measurement). Based on the 3-months questionnaire, participants were categorized as nonexercisers (n = 105), minimal low-impact exercisers (n = 249), regular low-impact exercisers (n = 117), and high-impact exercisers (n = 32). Between-group differences and within-group changes from 3 to 12 months were calculated using Chi-square tests, Kruskal-Wallis tests, and Friedman analysis of variance. RESULTS: At 3 months, no differences in symptom prevalence were seen between the groups. Nonexercisers reported higher pelvic girdle pain severity and had weaker pelvic floor muscles. The within-group analysis showed that pelvic girdle pain severity did not change in nonexercisers or high-impact exercisers, but decreased in minimal and regular low-impact exercisers. Stress urinary incontinence increased in nonexercisers from 3 to 12 months, while it remained unchanged in regular low-impact and high-impact exercisers, and decreased in minimal low-impact exercisers. Across all groups, vaginal heaviness and DRA decreased, and pelvic floor strength increased from 3 to 12 months. CONCLUSION: The study indicates that early low-impact exercising is associated with reduced pelvic girdle pain severity during the first postpartum year. Minimal low-impact exercisers also showed a slight reduction in stress urinary incontinence. Conversely, nonexercisers reported an increase in stress urinary incontinence between 3 and 12 months postpartum. IMPACT: Physical therapists should encourage women to start with low-impact exercise early after pregnancy. LAY SUMMARY: This study highlights the positive effects of starting gentle, low-impact exercise early after childbirth to reduce pelvic girdle pain and urinary incontinence.

Expertise and individually tailored interventions are expected by pregnant women with pelvic girdle pain who seek physical therapy: a qualitative study.

BACKGROUND: Pelvic girdle pain (PGP) in pregnancy may result in activity limitations and thus a negative impact on the individual woman's everyday life. Women's expectations when they seek physical therapy because of PGP are not yet known. OBJECTIVE: To explore pregnant women's lived experience of PGP and what needs and expectations they express prior to a physical therapy consultation. METHODS: A qualitative study using a descriptive phenomenological method. Interviews conducted with 15 pregnant women seeking physical therapy because of PGP, recruited through purposive sampling at one primary care rehabilitation clinic. RESULTS: PGP was described by four themes; An experience with larger impact on life than expected, A time for adjustments and acceptance, A feeling of insecurity and concern, A desire to move forward. PGP had a large impact on the pregnant women´s life. Thoughts of PGP as something to be endured was expressed, the women therefore accepted the situation. Finding strategies to manage everyday life was hard and when it failed, the women described despair and a need for help. They expected the physical therapist to be an expert who would see them as individuals and provide advice that could make their everyday life easier. CONCLUSION: Our results reveal that pregnant women with PGP delay seeking physical therapy until their situation becomes unmanageable and they run out of strategies for self-care. The women express, in light of their individual experiences, needs and expectations for professional management and advice tailored to their individually unique situation.

Can Clinical Postpartum Muscle Assessment Help Predict the Severity of Postpartum Pelvic Girdle Pain? A Prospective Cohort Study.

OBJECTIVE: The purpose of this study was to evaluate whether the clinical assessment of pelvic floor muscles and the diastasis recti abdominis could predict the severity of pelvic girdle pain during the first year postpartum. METHODS: Between 2018 and 2020, 504 women were recruited to this prospective longitudinal cohort study. At 2 to 3 months postpartum, their pelvic floor muscles and diastasis recti abdominis were assessed using vaginal palpation, observation, and caliper measurement. The participants completed the Pelvic Girdle Questionnaire (PGQ) at 2 to 3, 6, 9, and 12 months postpartum. Mixed-effect models were used to determine how the results of pelvic floor muscle and diastasis recti abdominis assessments predicted the PGQ score. A sub-analysis for middle to high PGQ scores was conducted. RESULTS: Maximal voluntary pelvic floor muscle contractions ≥3 (Modified Oxford Scale, scored from 0 to 5) predicted a decreased PGQ score (ß = -3.13 [95% CI = -5.77 to -0.48]) at 2 to 3 months postpartum, with a higher prediction of a middle to high PGQ score (ß = -6.39). Diastasis recti abdominis width did not have any significant correlation with the PGQ score. A sub-analysis showed that a diastasis recti abdominis width ≥35 mm predicted an increased PGQ score (ß = 5.38 [95% CI = 1.21 to 9.55]) in women with pelvic girdle pain. CONCLUSION: The distinction between weak and strong maximal voluntary pelvic floor muscle contractions is an important clinical assessment in women with postpartum pelvic girdle pain. The exact diastasis recti abdominis width, measured in millimeters, showed no clinical relevance. However, a diastasis recti abdominis width ≥35 mm was associated with a higher PGQ score, and further research about this cutoff point in relation to pain is needed. IMPACT: This study highlights the importance of clinical assessment of pelvic floor muscles in patients with postpartum pelvic girdle pain. A better understanding of the role of this muscle group will enable more effective physical therapist treatment of pelvic girdle pain.

Swedish validation of the Pelvic Floor Questionnaire for pregnant and postpartum women.

INTRODUCTION AND HYPOTHESIS: The German "Pelvic Floor Questionnaire for pregnant and postpartum women" is a self-administered questionnaire customized for pregnancy and the postpartum period that assesses four domains of pelvic floor function regarding perceived symptoms, suffering, and impact on quality of life: bladder, bowel, prolapse, and sexual function. No similar questionnaire is available in Swedish, despite a high prevalence of pregnancy and postpartum pelvic floor dysfunction. Thus, we aimed to translate the validated German questionnaire into Swedish and test its validity and reliability in a Swedish population. METHODS: Translation and cultural adaptation were performed according to guidelines. Of the 248 women who answered the Swedish questionnaire, 57 filled out the questionnaire twice to evaluate test-retest reliability. We also assessed internal consistency and discriminant validity. RESULTS: The Swedish version of the questionnaire showed good face and content validity. Cronbach's alpha was in the acceptable to excellent range (bladder 0.82, bowel 0.78, prolapse 0.91, and sexual 0.83), showing adequate internal consistency. A comparison of means (≥ 1 point) showed that the questionnaire significantly (p < 0.05) distinguished between women who reported suffering and those who did not. Cohen's kappa for all individual items showed fair to almost perfect agreement (0.24-0.87) between test and retest scores. The intraclass correlation coefficients for domain scores (0.92-0.97) were all in an optimal range. CONCLUSIONS: The Swedish version of the questionnaire is a reliable and valid instrument for assessing pelvic floor disorders, symptom severity, and impact on quality of life during pregnancy and the postpartum period.

Women's experiences of obstetric anal sphincter injury and physical therapy interventions - A qualitative study.

BACKGROUND: During childbirth, women may suffer perineal injuries that can lead to persistent disorders. No interview study has investigated women's experience of obstetric anal sphincter injuries (OASIS) and physical therapy rehabilitation process after the injury. OBJECTIVE: To describe women's experiences of OASIS and the physical therapy rehabilitation process. METHODS: A qualitative study with an inductive approach based on semi-structured interviews was performed with 14 primi- and multi-parous women affected by OASIS. They had been sutured within 24 h and were recruited from a university hospital in Sweden. The interviews lasted between 35 and 66 min. Data were processed and analyzed using qualitative content analysis. RESULTS: Three main categories emerged from the analysis: The categories described experiences of a difficult time after the injury and physical therapy rehabilitation but also experiences of a safe follow-up. Moreover, experiences of that it wasn´t that bad after all when looking back. CONCLUSION: Regardless of the extent of the injury, some women experienced a long and troublesome recovery with intense physical therapy rehabilitation, while other women felt that they fortunately got away lightly. Factors that can influence a woman's confidence in safely beginning pelvic floor muscle training at an early stage include individualizing when and how information about OASIS is provided. Meeting each woman's needs and wishes is emphasized by this study.

Women's experiences of the injury, recovery and desire for rehabilitation after a second-degree vaginal tear-a qualitative study.

INTRODUCTION AND HYPOSTHESIS: Eighty-five percent of all vaginal deliveries cause some form of obstetric tear injury. To our knowledge, there are no studies exploring experiences after second-degree tear. Therefore, our study aimed to investigate the experiences of a second-degree vaginal tear regarding aspects of the recovery and need for healthcare and rehabilitation. METHODS: Individual semi-structured interviews were performed and analysed with a qualitative, inductive descriptive approach. RESULTS: A group of 18 women with a second-degree vaginal tear after delivery were included. Four main categories with associated subcategories were found: (1) feeling uncertainty, with subcategories: not knowing what is normal, concern, confusion and uncertainty regarding pelvic floor muscle training; (2) feeling of security, with subcategories: I have no/I can handle the symptoms, trust in the healthcare system and I have sufficient knowledge; (3) not prioritizing myself, with the subcategories: I cannot find time and others have bigger problems; (4) lack of trust in healthcare providers, with the subcategories: feeling forgotten, not being taken seriously, distrust of the competence of the healthcare providers and resignation. CONCLUSION: Women who suffer from a second-degree vaginal tear after pregnancy can feel safe when needs are met but uncertainty is also common when available healthcare and information are perceived as insufficient. The women also feel uncertainty about what is normal after the tear and how to perform pelvic floor exercises. TRIAL REGISTRATION: This trial was registered in "FoU in Sweden" (Research and Development in Sweden). REGISTRATION NUMBER: 214591 .

Lifestyle and Chronic Pain in the Pelvis: State of the Art and Future Directions.

During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women's lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman's life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.

Maintenance of physical activity level, functioning and health after non-pharmacological treatment of pelvic girdle pain with either transcutaneous electrical nerve stimulation or acupuncture: a randomised controlled trial.

OBJECTIVE: To investigate if there are differences between acupuncture and transcutaneous electrical nerve stimulation (TENS) as treatment for pelvic girdle pain (PGP) in pregnancy in order to manage pain and thus maintain health and functioning in daily activities and physical activity (PA). DESIGN: Randomised controlled trial. SETTING AND PARTICIPANTS: Pregnant women (n=113) with clinically verified PGP in gestational weeks 12-28, recruited from maternity healthcare centres, randomised (1:1) into two groups. EXCLUSION CRITERIA: any obstetrical complication, systemic disease or previous disorder that could contradict tests or treatment. INTERVENTIONS: The intervention consisted of either 10 acupuncture sessions (two sessions per week) provided by a physiotherapist or daily home-based TENS during 5 weeks. PRIMARY OUTCOME VARIABLES: Disability (Oswestry Disability Index), functioning (Patient Specific Functional Scale), work ability (Work Ability Index) and PA-level according to general recommendations. SECONDARY OUTCOME VARIABLES: Functioning related to PGP (Pelvic Girdle Questionnaire), evening pain intensity (Numeric Rating Scale, NRS), concern about pain (NRS), health (EuroQoL 5-dimension), symptoms of depression/catastrophising (Edinburgh Postnatal Depression Scale/Coping Strategies Questionnaire). RESULTS: No mean differences were detected between the groups. Both groups managed to preserve their functioning and PA level at follow-up. This may be due to significantly (p<0.05) reduced within groups evening pain intensity; acupuncture -0.96 (95% CI -1.91 to -0.01; p=0.049), TENS -1.29 (95% CI -2.13 to -0.44; p=0.003) and concern about pain; acupuncture -1.44 (95% CI -2.31 to -0.57; p=0.0012), TENS -1.99 (95% CI -2.81 to -1.17; p<0.0001). The acupuncture group showed an improvement in functioning at follow-up; 0.82 (95% CI 0.01 to 1.63; p=0.048) CONCLUSION: Treating PGP with acupuncture or TENS resulted in maintenance of functioning and physical activity and also less pain and concern about pain. Either intervention could be recommended as a non-pharmacological alternative for pain relief and may enable pregnant women to stay active. TRIAL REGISTRATION NUMBER: 12726. https://www.researchweb.org/is/sverige/project/127261.

Clinical assessment of pelvic floor and abdominal muscles 3 months post partum: an inter-rater reliability study.

OBJECTIVES: Evaluation of the inter-rater reliability of clinical assessment methods for pelvic floor muscles and diastasis recti abdominis post partum. DESIGN: A multicentre inter-rater reliability study. SETTING: Three primary care rehabilitation centres in Sweden. PARTICIPANTS: A total of 222 participants were recruited via advertising at Swedish maternity care units and social media. Eligibility for participation included female gender, ≥18 years, at maximum 3 months after childbirth. Exclusion criteria were chronic pelvic girdle pain and/or low back pain and/or pelvic floor tear grade III/IV. At each centre, 2 physiotherapists, with training and experience in pelvic floor assessment, assessed the 222 women according to a standardised protocol in random order. OUTCOME MEASURES: Inter-rater reliability of the assessment of pelvic floor muscle function (involuntary and voluntary contraction and voluntary relaxation) and diastasis recti abdominis (width, depth and bulging). RESULTS: Vaginal palpation of maximal voluntary contraction revealed a kappa value of 0.69 (95% CI 0.62 to 0.76). Assessments of involuntary contraction and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10 to 0.51. After 2 months of training in applying this method, diastasis recti abdominis width measured at the umbilicus by calliper yielded an intraclass correlation coefficient value of 0.83 (95% CI 0.76 to 0.87). Assessments of diastasis recti abdominis depth and bulging showed moderate kappa values, with reservation for some inconsistency between the centres. CONCLUSIONS: Vaginal palpation of pelvic floor muscle strength is a reliable method for the postpartum muscle assessment. Additional research is needed to identify reliable assessment method for other pelvic floor muscle functions like involuntary contraction and voluntary relaxation. With some training, a calliper is a reliable instrument for measuring the postpartum diastasis recti abdominis width. This study provides novel thoughts about how to measure diastasis recti abdominis depth and bulging. TRIAL REGISTRATION NUMBER: NCT03703804.

Validation of self-administered tests for screening for chronic pregnancy-related pelvic girdle pain.

BACKGROUND: Many women develop pelvic girdle pain (PGP) during pregnancy and about 10% have chronic pain several years after delivery. Self-administered pain provocation tests are one way to diagnose and evaluate this pain. Their validity in post-partum women is not yet studied. The purpose of this study was to evaluate the validity of self-administered test for assessment of chronic pregnancy-related PGP several years after delivery. METHODS: Women who previously have had PGP during pregnancy and who participated in one of three RCT studies were invited to a postal follow up of symptoms including performance of self-administered tests after two, 6 or 11 years later, respectively. In total, 289 women returned the questionnaire and the test-results. Of these, a sub-group of 44 women with current PGP underwent an in-person clinical examination. Comparisons were made between test results in women with versus without PGP but also, in the sub-group, between the self-administered tests and those performed during the clinical examination. RESULTS: Fifty-one women reported PGP affecting daily life during the last 4 weeks, and 181 reported pain when performing at least one of the tests at home. Those with chronic PGP reported more positive tests (p < 0.001). There was no significant difference between diagnosis from the self-administered tests compared to tests performed during the in-person clinical examination (p = 0.305), either for anterior or posterior PGP. There were no significant differences of the results between the tests performed self-administered vs. during the clinical examination. CONCLUSION: A battery of self-administered tests combined with for example additional specific questions or a pain-drawing can be used as a screening tool to diagnose chronic PGP years after delivery. However, the modified SLR test has limitations which makes its use questionable.

A core outcome set for research and clinical practice in women with pelvic girdle pain: PGP-COS.

BACKGROUND: Inconsistent reporting of outcomes in clinical trials of women with Pelvic Girdle Pain (PGP) hinders comparison of findings and the reliability of evidence synthesis. A core outcome set (COS) can address this issue as it defines a minimum set of outcomes that should be reported in all clinical trials on the condition. The aim of this study was to develop a consensus-based COS for evaluating the effectiveness of interventions in PGP during pregnancy and postpartum for use in research and clinical practice. METHODS: A systematic review of previous studies on PGP and semi-structured interviews with women were undertaken to identify all outcomes that were reported in prior studies and that are relevant to those experiencing the condition. Key stakeholders (clinicians, researchers, service providers/policy makers and individuals with PGP) then rated the importance of these outcomes for including in a preliminary PGP-COS using a 3-round Delphi study. The final COS was agreed at a face-to-face consensus meeting. RESULTS: Consensus was achieved on five outcomes for inclusion in the final PGP-COS. All outcomes are grouped under the "life impact" domain and include: pain frequency, pain intensity/severity, function/disability/activity limitation, health-related quality of life and fear avoidance. CONCLUSION: This study identified a COS for evaluating the effectiveness of interventions in pregnancy-related and postpartum-related PGP in research and clinical settings. It is advocated that all trials, other non-randomised studies and clinicians in this area use this COS by reporting these outcomes as a minimum. This will ensure the reporting of meaningful outcomes and will enable the findings of future studies to be compared and combined. Future work will determine how to measure the outcomes of the PGP-COS. CORE OUTCOME SET REGISTRATION: This PGP-COS was registered with COMET (Core Outcome Measures for Effectiveness Trials) in January 2017 (http://www.comet-initiative.org/studies/details/958).

The use of physical exercise in forensic psychiatric care in Sweden: a nationwide survey.

BACKGROUND: Exercise protects against somatic comorbidities and positively affects cognitive function and psychiatric symptoms in patients with severe mental illness. In forensic psychiatry, exercise is a novel concept. Staff at inpatient care facilities may be important resources for successful intervention. Little is known about staff's knowledge, attitudes and behaviors regarding exercise in forensic psychiatric care. AIMS: To translate, culturally adapt and test the feasibility of the Exercise in Mental Health Questionnaire-Health Professionals Version (EMIQ-HP) in the Swedish context, and to use this EMIQ-HP-Swedish version to describe staff's knowledge, attitudes and behaviors regarding exercise. METHOD: The EMIQ-HP was translated, culturally adapted, pilot-tested and thereafter used in a cross-sectional nationwide survey. RESULTS: Ten of 25 clinics and 239 health professionals (50.1%) participated. Two parts of the EMIQ-HP-Swedish version showed problems. Most participants considered exercise to be a low-risk treatment (92.4%) that is beneficial (99.2%). Training in exercise prescription was reported by 16.3%. Half of participants (52.7%) prescribed exercise and 50.0% of those undertook formal assessments prior to prescribing. CONCLUSIONS: Creation of the EMIQ-HP-Swedish version was successful, despite some clarity problems. Exercise appears to be prescribed informally by non-experts in Swedish forensic psychiatric care and does not address treatment goals.

The Swedish version of the pelvic girdle questionnaire, cross-cultural adaptation and validation.

Purpose: The aims of this study were to translate and culturally adapt The Pelvic Girdle Questionnaire to Swedish, and to evaluate the construct and discriminative validity.Materials and methods: A translation and cultural adaptation process was performed according to international guidelines. Pilot tests were conducted among 16 women during pregnancy and post-partum. Analysis of the construct and discriminative validity of the Swedish version of the Pelvic Girdle Questionnaire was performed in a sample of 177 pregnant women suffering from pain in the lumbo-pelvic area. Participants completed the Pelvic Girdle Questionnaire along with Oswestry Disability Index, numeric rating scales for pain intensity and for pelvic girdle pain concerns.Results: The Swedish version of the Pelvic Girdle Questionnaire showed high internal consistency with Cronbach's alphas between 0.82 and 0.96, good convergent validity with high correlations with the Oswestry Disability Index and the pain intensity numeric rating scale, whereas moderate correlation was shown between the concerns numeric rating scale and the other instruments as hypothesized. Receiver operating characteristic curves showed good discriminatory capacity for women in need of treatment.Conclusions: The Swedish version of the Pelvic Girdle Questionnaire has patient acceptability. It has good construct and discriminative validity for measurements of consequences of pregnancy-related pelvic girdle pain among Swedish speaking women.IMPLICATIONS FOR REHABILITATIONPregnancy-related pelvic girdle pain may be disabling and long-lasting, however treatable when identified.The Pelvic Girdle Questionnaire is the only condition-specific, reliability tested and validated questionnaire for pelvic girdle pain.The Swedish version of the Pelvic Girdle Questionnaire has patient acceptability, good construct validity for pelvic girdle pain among Swedish speaking women, and shows good discriminative capacity for women in need of treatment.

Physical performance and physical activity of patients under compulsory forensic psychiatric inpatient care.

Research stresses the importance of physical activity in general psychiatric care. There is very little research made in the area of forensic psychiatric care. The aim of this exploratory, cross-sectional study was to assess various physical, psychological, and health variables of patients under compulsory forensic psychiatric inpatient care, and to examine correlations among these variables. Maximal oxygen uptake (VO2max), walking ability, running speed, and explosive leg strength were examined in 28 patients. Patients answered questionnaires about physical activity, aggression, stress, character maturity, and health-related quality of life (HRQL). The patients had a mean age of 33.6 years, a mean VO2max of 25.3 (8.4) mL 02/min/kg and a mean physical activity level of 268.0 (272.4) min/week. Results from the 6-min walk test were 612.5 (102.8) m. Nine patients had physical activity levels below the international recommendations of 150 min/week. Levels of aggression and stress were high and HRQL was low. The results indicate that patients in forensic psychiatric care are in a very poor physical state, which warrants physiotherapeutic interventions, adapted to the unique demands of forensic psychiatric care.

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts.

BACKGROUND: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

A Person-Centered Prehabilitation Program Based on Cognitive-Behavioral Physical Therapy for Patients Scheduled for Lumbar Fusion Surgery: A Randomized Controlled Trial.

BACKGROUND: Prehabilitation programs have led to improved postoperative outcomes in several surgical contexts, but there are presently no guidelines for the prehabilitation phase before lumbar fusion surgery. OBJECTIVE: The objective was to investigate whether a person-centered physical therapy prehabilitation program, based on a cognitive-behavioral approach, is more effective than conventional care in reducing disability and improving functioning after lumbar fusion surgery in patients with degenerative disk disease. DESIGN: This study was a randomized controlled trial. SETTING: The study took place at 2 private spine clinics and 1 university hospital. PATIENTS: We prospectively enrolled 118 patients scheduled for lumbar fusion surgery. INTERVENTION: The active intervention used a person-centered perspective and focused on promoting physical activity and targeting psychological risk factors before surgery. The control group received conventional preoperative care. MEASUREMENTS: The primary outcome was the Oswestry Disability Index score. Secondary outcomes were back and leg pain intensity, catastrophizing, kinesiophobia, self-efficacy, anxiety, depression, health-related quality of life, and patient-specific functioning, physical activity, and physical capacity. Data were collected on 6 occasions up to 6 months postoperatively. A linear mixed model was used to analyze the change scores of each outcome. RESULTS: No statistically significant between-group difference was found on the primary outcome (disability) over time (baseline to 6 months). Among secondary outcome measures, a statistically significant interaction effect ("Group × Time") was seen for the European Quality of Life 5 Dimensions Questionnaire. The largest between-group difference on the European Quality of Life 5 Dimensions Questionnaire index was seen 1 week prior to surgery and favored the active intervention. The largest between-group effect sizes at the 6-month follow-up favored the active intervention, and were seen for physical activity intensity, steps per day, and the One Leg Stand Test. Both groups reached the minimal important change for the primary outcome and, in several secondary outcomes (pain intensity, back and leg; pain catastrophizing; anxiety; health-related quality of life [EQ5D VAS]), already at 8-week follow-up. LIMITATIONS: The participants' preoperative level of disability was lower than normative values, which suggests selection bias. CONCLUSIONS: Both interventions led to clinically important changes, but it is not clear what kind of prehabilitation program is the most effective.

One-minute stair climbing, 50-foot walk, and timed up-and-go were responsive measures for patients with chronic low back pain undergoing lumbar fusion surgery.

BACKGROUND: Physical capacity tasks are useful tools to assess functioning in patients with low back pain (LBP), but evidence is scarce regarding the responsiveness (ability to detect change over time) and minimal important change (MIC). The aim was to investigate the responsiveness and MIC of 5-min walk, 1-min stair climbing, 50-ft walk, and timed up-and-go in patients with chronic LBP undergoing lumbar fusion surgery. METHODS: In this clinimetric study, 118 patients scheduled for lumbar fusion surgery for motion-elicited chronic LBP with degenerative changes were included. All patients performed the physical capacity tasks 5-min walk, 1-min stair climbing, 50-ft walk, and timed up-and-go 8-12 weeks before and six months after surgery. Responsiveness was evaluated by testing five a priori responsiveness hypotheses. The hypotheses concerned the area under the receiver operating characteristics (ROC) curve and correlations (Spearman's rho) between the change scores of the physical capacity tasks, the Oswestry Disability Index 2.0 (ODI), and back pain intensity measured with visual analog scale (VAS). At least 80% of the hypotheses would have to be confirmed for adequate responsiveness. Absolute and relative MICs for improvement were determined by the optimal cut-off point of the ROC curve based on the classification of improved and unchanged patients according to construct-specific global perceived effect (GPE) scales. RESULTS: One-minute stair climbing, 50-ft walk and timed up-and-go displayed adequate responsiveness (≥ 80% of hypotheses confirmed), while 5-min walk did not (40% of hypotheses confirmed). The absolute MICs for improvement were 45.5 m for 5-min walk, 20.0 steps for 1-min stair climbing, - 0.6 s for 50-ft walk, and - 1.3 s for timed up-and-go. CONCLUSIONS: The results of responsiveness for 1-min stair climbing, 50-ft walk, and timed up-and-go implies that these have the ability to detect changes in physical capacity over time in patients with chronic LBP who have undergone lumbar fusion surgery.