Barriers and facilitators to engaging with a digital self-management programme for painful distal upper limb musculoskeletal disorders: A qualitative exploratory study.

INTRODUCTION: People living with a painful distal upper limb musculoskeletal disorder (DUL-MSD) often experience pain, difficulty in doing everyday tasks and a reduced quality of life. Currently, there are challenges in the treatment of DUL-MSDs, highlighting the need to develop innovative approaches to rehabilitation. A potential solution is to develop and implement a digital self-management rehabilitation programme focussing on optimising recovery, improving function and reducing pain. Before developing this programme, we aimed to identify the barriers and facilitators to using a digital health intervention (DHI) for self-management of DUL-MSDs. OBJECTIVE: This study aimed to investigate the potential barriers and facilitators to using a DHI with people living with DUL-MSDs and healthcare professionals (HCPs). METHODS: A qualitative exploratory study was carried out with purposely selected participants consisting of 15 participants with DUL-MSDs and 13 HCPs. Three focus groups (FGs) and four semistructured interviews with DUL-MSD participants and semistructured interviews with 13 HCPs were conducted. FGs and interviews were digitally recorded, transcribed and analysed using reflexive thematic analysis. RESULTS: To address challenges in the care and management of DUL-MSDs, both HCPs and people living with a DUL-MSD welcomed the development of a DHI. This study identified several barriers and facilitators that would influence engagement with a digital intervention. Findings suggest that in developing a DHI, attention needs to be paid to digital design features, usability, tailoring, personalisation and consideration of how well usual care could be replicated digitally without direct HCP involvement. CONCLUSION: The identified digital design features of importance to participants will inform the design of a digital self-management rehabilitation programme for people living with DUL-MSDs. Addressing the barriers and facilitators to engagement with a DHI is essential in ensuring its relevance and acceptability to those who will use it. PATIENT OR PUBLIC CONTRIBUTION: Patient and Public Involvement and Engagement (PPIE) was integral throughout the study. PPIE members contributed to the development and planning of this study, checked and confirmed the relevance of the findings and are involved in the dissemination plans.

Response Shifts in the Canadian Occupational Performance Measure: A Convergent Mixed-Methods Study.

IMPORTANCE: A response shift (RS) is a phenomenon in which there is an individual perceptual gap between pre and post assessments. RS effects were not considered in the Canadian Occupational Performance Measure (COPM) development process. OBJECTIVE: To detect the effects of RS on the COPM. DESIGN: Convergent mixed-methods research. SETTING: Subacute rehabilitation hospital in Japan. PARTICIPANTS: Nineteen adult patients with a range of neurological and musculoskeletal conditions recruited from a subacute rehabilitation hospital. OUTCOMES AND MEASURES: In the qualitative analysis, patients' perceptions regarding occupation identified by the COPM were compared between the initial assessment (Time 1 [T1]) and a reassessment (Time 2 [T2]). In the quantitative study, patients were asked to re-rate the occupations in which the RS had occurred, giving feedback on their perceptions at T1 (T2'). The difference between T2 and T2' was calculated to clarify the magnitude of the RS. RESULTS: Of the 19 patients, 18 had an RS in at least one occupation. The RS effects were classified into five categories: Replacing, Adding, Reducing, Unspecified, and Embodiment. Ninety occupations were extracted from all the patients, and 46 (51.1%) were affected by RS. The percentages of occupations for which the change in score due to RS exceeded the minimal clinically important difference (±2 points) was 26.1% (12 of 46) for COPM-Performance scores and 30.4% (14 of 46) for COPM-Satisfaction scores. CONCLUSIONS AND RELEVANCE: Diverse RS effects have been identified in the COPM, which also affect score interpretation. Plain-Language Summary: The Canadian Occupational Performance Measure has a potential measurement bias that is due to a response shift in which there is an individual perceptual gap between pre and post assessments. The results of this study reveal a need to establish more accurate measurement methods to reduce the impact of response shifts on COPM scores.

[Analgesics, chronic pain and musculoskeletal rehabilitation]. / Médicaments antalgiques, douleur chronique et réadaptation de l'appareil locomoteur.

The majority of patients following musculoskeletal rehabilitation are taking painkillers. However, apart from one recent observational study, there is a lack of data. The use of analgesics, particularly opioids, is associated with higher scores for pain, anxiety, depression, catastrophizing and disability, as well as poorer results in functional tests. Prescribing analgesic treatment with precise objectives (improving pain and function) should also include identifying psychosocial factors associated with a poor prognosis. Regular reassessment of the treatment should make it possible to limit side-effects and the risk of misuse and help patients to engage in an active rehabilitation programme and resume regular physical activity.

La majorité des patients effectuant une réadaptation musculosquelettique consomme des antalgiques. Cependant, en dehors d'une étude observationnelle récente, les données manquent. La prise d'antalgiques, en particulier les opioïdes, est associée à des scores de douleur, d'anxiété, de dépression, de catastrophisme et de handicap élevés, ainsi qu'à des résultats plus faibles aux tests fonctionnels. La prescription d'un traitement antalgique avec des objectifs précis (amélioration de la douleur et de la fonction) doit également comporter une détection des facteurs psychosociaux de mauvais pronostic. Une réévaluation régulière de la prescription devrait permettre de limiter les effets secondaires, les risques de mésusage et aider les patients à s'engager dans un programme de réadaptation actif et à reprendre une activité physique régulière.

Psychometric properties of the readiness for return to work scale in occupational rehabilitation in South Korea.

BACKGROUND: This study validated the Korean version of the Readiness to Return to Work (RRTW) scale, as an assessment measure, following a musculoskeletal, work-related injury and as a measure of following return to work. METHODS: The participants of this study were workers with experience in rehabilitation programs at the Workers' Compensation and Welfare Service (KCOMWEL) Hospital in Korea. Factor analyses were employed to ensure the validity and reliability of the RRTW scale in claimants who were in treatment without working (the not-working group) or who had already returned to work (the working group). To test structural validity, we analyzed exploratory factor analysis (EFA) respectively for the not working group (exploratory factor analysis (EFA) (n = 200), confirmatory factor analysis (CFA) (n = 109), and the working group (n = 123). To verify concurrent validity (multidimensional and assignment approach), the variables that were identified as relevant variables in previous studies were analyzed. RESULTS: The not working group EFA, as shown in the original scale, had four dimensions, and one item was deleted: (1) Precontemplation (PC), (2) Contemplation (C), (3) Prepared for Action-Self-evaluative (PAS), and (4) Prepared for Action-Behavioral (PAB). The CFA revealed that a good model fit and reliability were suitable. Regarding the working group of EFA, it appeared in two dimensions as in the original scale, one item was modified from the UM scale to the PM scale, and the reliability was appropriate. Concurrent validity was satisfied based on the correlation between the RRTW factor and related variables. CONCLUSIONS: RRTW in the Korean version of the instrument was similar to those reported for the original scale, indicating that it may be used in research and clinical settings.

Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019.

BACKGROUND: Rehabilitation has often been seen as a disability-specific service needed by only few of the population. Despite its individual and societal benefits, rehabilitation has not been prioritised in countries and is under-resourced. We present global, regional, and country data for the number of people who would benefit from rehabilitation at least once during the course of their disabling illness or injury. METHODS: To estimate the need for rehabilitation, data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 were used to calculate the prevalence and years of life lived with disability (YLDs) of 25 diseases, impairments, or bespoke aggregations of sequelae that were selected as amenable to rehabilitation. All analyses were done at the country level and then aggregated to seven regions: World Bank high-income countries and the six WHO regions (ie, Africa, the Americas, Southeast Asia, Europe, Eastern Mediterranean, and Western Pacific). FINDINGS: Globally, in 2019, 2·41 billion (95% uncertainty interval 2·34-2·50) individuals had conditions that would benefit from rehabilitation, contributing to 310 million [235-392] YLDs. This number had increased by 63% from 1990 to 2019. Regionally, the Western Pacific had the highest need of rehabilitation services (610 million people [588-636] and 83 million YLDs [62-106]). The disease area that contributed most to prevalence was musculoskeletal disorders (1·71 billion people [1·68-1·80]), with low back pain being the most prevalent condition in 134 of the 204 countries analysed. INTERPRETATION: To our knowledge, this is the first study to produce a global estimate of the need for rehabilitation services and to show that at least one in every three people in the world needs rehabilitation at some point in the course of their illness or injury. This number counters the common view of rehabilitation as a service required by only few people. We argue that rehabilitation needs to be brought close to communities as an integral part of primary health care to reach more people in need. FUNDING: Bill & Melinda Gates Foundation.

Do patient characteristics affect the predictive validity of Functional Capacity Evaluations?

PURPOSE: The aim of this study was to identify patient-related characteristics that affect the predictive validity of the FCE assessment ELA. METHODS: A prospective multicenter study was conducted on 303 patients with musculoskeletal disorders (MSD) recruited from eleven rehabilitation centers. The ELA-based estimation of the participants' ability to cope with physical work demands was considered valid if RTW was paired with a positive ELA outcome (≥ moderate) as well as if non-RTW was accompanied by a negative ELA outcome (rather or very poor). In the remaining cases, the ELA result was judged as non-valid. To reduce the risk of false conclusions, the rating was performed inversely in participants that (1) reported severe limitations regarding their productivity at work, (2) attributed RTW to a change in job resp. a reduction of their physical work demands and in those that (3) attributed non-RTW to non-physical reintegration barriers only. Using questionnaires, 28 patient-related characteristics were collected. Logistic regression models were calculated to identify characteristics that affected the predictive validity of ELA. RESULTS: ELA was considered valid in 208 of 303 (69%) participants. A moderate and strong pain-related disability at work were associated with a 0.15-fold (95% confidence interval (95% CI) 0.05-0.46), respectively, 0.19-fold (95% CI 0.05-0.72) chance for a valid outcome. In addition, a negative influence was found in participants that reported psychosocial distress (odds ratio (OR) 0.35; 95% CI 0.15-0.82), a native language different from the national language (OR 0.16; 95% CI 0.05-0.56) as well as in those that expected to return to work, but not within one month (OR 0.17; 95% CI 0.06-0.46). Further variables-including age, employment status, fear-avoidance beliefs and the level of physical work demands-did not affect the predictive validity of ELA. CONCLUSIONS: The results suggest that the predictive validity of ELA is primarily limited by patients that report a moderate or strong pain-related disability at work, psychosocial distress as well as the expectation to return to work, but not within one month. Furthermore, a negative influence can be assumed for language barriers.

Associations between quality of health care and clinical outcomes in patients with rheumatic and musculoskeletal diseases: a rehabilitation cohort study.

BACKGROUND: The quality of provided health care may be an important source of variation in rehabilitation outcomes, increasing the interest in associations between quality indicators (QIs) and improved patient outcomes. Therefore, we examined the associations between the quality of rehabilitation processes and subsequent clinical outcomes among patients with rheumatic and musculoskeletal diseases (RMDs). METHODS: In this multicentre prospective cohort study, adults with RMDs undergoing multidisciplinary rehabilitation at eight participating centres reported the quality of rehabilitation after 2 months and outcomes after 2, 7, and 12 months. We measured perceived quality of rehabilitation by 11 process indicators that cover the domains of initial assessments, patient participation and individual goal-setting, and individual follow-up and coordination across levels of health care. The patients responded "yes" or "no" to each indicator. Scores were calculated as pass rates (PRs) from 0 to 100% (best score). Clinical outcomes were goal attainment (Patient-Specific Functional Scale), physical function (30 s sit-to-stand test), and health-related quality of life (EuroQoL 5D-5L). Associations between patient-reported quality of care and each outcome measure at 7 months was analysed by linear mixed models. RESULTS: A total of 293 patients were enrolled in this study (mean age 52 years, 76% female). Primary diagnoses were inflammatory rheumatic disease (64%), fibromyalgia syndrome (18%), unspecific neck, shoulder, or low back pain (8%), connective tissue disease (6%), and osteoarthritis (4%). The overall median PR for the process indicators was 73% (range 11-100%). The PR was lowest (median 40%) for individual follow-up and coordination across levels of care. The mixed model analyses showed that higher PRs for the process indicators were not associated with improved goal attainment or improved physical function or improved health-related quality of life. CONCLUSIONS: The quality of rehabilitation processes was not associated with important clinical outcomes. An implication of this is that measuring only the outcome dimension of quality may result in incomplete evaluation and monitoring of the quality of care, and we suggest using information from both the structure, process, and outcome dimensions to draw inferences about the quality, and plan future quality initiatives in the field of complex rehabilitation. TRIAL REGISTRATION: The study is part of the larger BRIDGE trial (ClinicalTrials.gov NCT03102814 ).

Matching Perceived Physical Capacity and Work Demands: A New Classification of the Modified Spinal Function Sort (M-SFS).

Purpose The aims of this study were (1) to develop a new classification for the scores of the Modified Spinal Function Sort (M-SFS) which is related to the level of physical work demands and (2) to test the predictive value of the M-SFS classification. Methods The classification was carried out in 194 subjects with musculoskeletal disorders (MSD) attending a work-related medical rehabilitation from four rehabilitation centers. External criterion was a Functional Capacity Evaluation (FCE)-based work capacity estimation according to the classification used in Germany ("REFA") which differentiates between light, light to medium, medium and heavy work. The optimal cut-offs for the M-SFS were allocated using the Youden index. Logistic regression models were calculated based on 147 subjects who participated in the follow-up survey to evaluate the predictive validity of the M-SFS classification with regard to sustainable return to work (RTW; employment at the 3-month follow-up combined with a low level of sick leave). Results Cut-offs for M-SFS scores were 44 (light work), 54 (light to medium work), 62 (medium work) and 73 (heavy work). A match between the M-SFS category and the level of physical work demands was associated with a more than threefold higher RTW chance compared to subjects with a negative discrepancy. In case the M-SFS category was above the physical demand level the RTW-chance was more than 13-fold higher. Conclusions M-SFS scores can be classified into four levels of physical work demands. If the perceived work capacity matches or exceeds the level of physical work demands patients with MSD have a substantially higher probability to return to work after rehabilitation. More studies are needed to confirm or reject our findings and overcome some of the weaknesses of this study.

Competencies for Physiotherapists Working to Facilitate Rehabilitation, Work Participation and Return to Work for Workers with Musculoskeletal Disorders: A Scoping Review.

Purpose The aim of this scoping review was to synthesize the literature addressing the competencies that physiotherapists in a clinical setting need to facilitate the rehabilitation, work participation, and return to work of workers with musculoskeletal disorders.Methods We conducted a scoping review in accordance with Arksey & O'Malley's five-step method. The following categories of keywords were used during searches in Embase, Medline and CINAHL in May 2020: (1) physiotherapy/physical therapy; (2) return to work, work participation or occupational health; and (3) education/professional competencies/guidelines. Two authors reviewed the full-text papers and agreed on the selection of articles for inclusion. The selected articles were then charted in an Excel grid and descriptively analyzed.Results Three main categories of competencies were identified: (1) Understanding and interacting with patients who are workers; (2) Planning rehabilitation with other stakeholders; and (3) Reaching out to the workplace. The fourth category named "Obstacles to the development of work-related competencies", regroups several obstacles that were identified as potentially impeding the development of work-related competencies by physiotherapists.Conclusion The findings of this scoping review inform physiotherapy clinicians, educators and regulators on the specific knowledge, skills, abilities, and attitudes that appear to play a role in facilitating the rehabilitation of workers with musculoskeletal disorders. We trust that this study will lead to new initiatives that will define, implement and evaluate the effectiveness of these competencies in practice, along with rekindling the discussions about the place of work rehabilitation in the physiotherapy profession.

SOME ASPECTS OF THE POTENTIAL ADHERENCE TO REHABILITATION OF PATIENTS WITH MUSCULOSKELETAL INJURIES.

OBJECTIVE: The aim: To investigate and analyse certain aspects of potential adherence to rehabilitation treatment of patients with musculoskeletal injuries. PATIENTS AND METHODS: Materials and methods: The study was conducted among 108 patients with musculoskeletal injuries. A questionnaire, containing 25 questions, was used to determine the importance for patients of rehabilitation treatment and their readiness to perform its measures. RESULTS: Results: It was found that for 98.0 ± 2.6% of surveyed patients with injuries it is important not to experience limitations in the future functioning of their bodies. 97.2 ± 3.1% of the surveyed patients with injuries indicated their readiness to do exercises prescribed by a rehabilitation specialist at home, and 87.0 ± 6.3% were ready to perform physical exercises even in case of unpleasant sensations or discomfort. It was determined that 67.6 ± 8.8% of the surveyed patients with injuries are ready to attend rehabilitation classes with specialists, 69.5 ± 8.7% are ready to record their own achievements at home and 73.1 ± 8.4% of the patients consent to maintain regular contact with rehabilitation specialists via the Internet. CONCLUSION: Conclusions: Patients with musculoskeletal injuries have a high level of understanding of the importance of rehabilitation. The vast majority of them are ready to perform most of the components of rehabilitation, but without significant changes in normal life and with a predominant stay at home. All this requires the development of organizational measures to form the adherence to particular components of rehabilitation.

Development and validity assessment of a Japanese version of the Exercise Adherence Rating Scale in participants with musculoskeletal disorders.

BACKGROUND: Exercise adherence is important for achieving a long-term effect from musculoskeletal management. The Exercise Adherence Rating Scale (EARS), which was developed in 2017 as a patient reported outcome measure to assess exercise adherence in those with chronic low back pain in the UK, has demonstrated acceptable validity and reliability and is a robust measure of exercise adherence. This study aimed to undertake cross-cultural adaptation of the EARS into Japanese and investigate its structural validity in participants with musculoskeletal disorders. METHODS: The current study was composed of two phases, where a provisional Japanese version of the EARS was developed employing an international guideline for cross-cultural adaptation (Phase A), and structural validity was then evaluated using the Rasch analysis (Phase B). Participants with musculoskeletal disorders who have individualized home exercises prescribed by a physical therapist were recruited. RESULTS: In Phase A, the pilot testing was conducted twice because the initial testing detected some uncertainty revealed in comments from 17 participants (5 males and 12 females, 18-79 years of age) about which activities and exercises were supposed to be included. We therefore modified the draft by identifying a person who prescribed/recommended activities and exercises as per the Working Alliance Inventory. The second pilot testing using this draft recruited 30 participants (6 males and 24 females, 18-79 years of age), who provided no further comments, demonstrating the Japanese version of the EARS (EARS-J) had been successfully developed. In Phase B, data from 200 participants who completed the EARS-J (63 males and 127 females, mean ± SD of age = 53.6 ± 17.0) were analyzed using the Andrich's Rating Scale Model. Rasch statics indicated unidimensionality of the six items of the EARS-J. The Cronbach α was 0.77. Substantial ceiling effect (21.0%) was observed, with no floor effect (0.5%). CONCLUSIONS: A Japanese version of the EARS has been developed, which demonstrated acceptable structural validity with the evidence of unidimensionality in the Rasch analysis in Japanese people with musculoskeletal disorders who were prescribed individualized home exercises. However, there was a substantial ceiling effect and further studies are required to comprehensively establish validity and reliability of the EARS-J.

Region-specific Exercises vs General Exercises in the Management of Spinal and Peripheral Musculoskeletal Disorders: A Systematic Review With Meta-analyses of Randomized Controlled Trials.

OBJECTIVE: To compare the efficacy of region-specific exercises to general exercises approaches for adults with spinal or peripheral musculoskeletal disorders (MSKDs). DATA SOURCES: Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health. STUDY SELECTION: Randomized control trials (RCTs) on the efficacy of region-specific exercises compared to general exercises approaches for adults with various MSKDs. DATA EXTRACTION: Mean differences and standardized mean differences were calculated using random-effects inverse variance modeling. Eighteen RCTs (n=1719) were included. Cohorts were composed of participants with chronic neck (n=313) or low back disorders (n=1096) and knee osteoarthritis (OA) (n=310). DATA SYNTHESIS: Based on low-quality evidence in the short-term and very low-quality in the mid- and long-term, there were no statistically significant differences between region-specific and general exercises in terms of pain and disability reductions for adults with spinal disorders or knee OA. Secondary analyses for pain reduction in the short-term for neck or low back disorders did not report any statistically significant differences according to very low- to low-quality of evidence. CONCLUSIONS: The difference in treatment effect remains uncertain between region-specific and general exercises approaches. Based on very low- to low-quality evidence, there appear to have no differences between both types of exercise approaches for pain reduction or disability for adults with spinal disorders. Future trials may change the current conclusions. More evidence is needed for region-specific exercises compared to general exercises for other peripheral MSKDs including knee OA.

The Lower Extremity Physical Function Patient-Reported Outcome Measure Was Reliable, Valid, and Efficient for Patients With Musculoskeletal Impairments.

OBJECTIVE: To calibrate the Lower Extremity Functional Scale (LEFS) items into a regional lower extremity physical function (LEPF) item bank and assess reliability, validity, and efficiency of computerized adaptive test (CAT) and short form (SF) administration modes. DESIGN: Retrospective cohort. SETTING: Data were collected from patients treated in outpatient rehabilitation clinics for musculoskeletal impairments of the hip, knee, foot, and ankle that responded to all 20 LEFS items at intake. PARTICIPANTS: Patients aged 14 years or older who started an episode of care during January 2016-October 2019 and identified the lower extremity region as the source of a primary musculoskeletal complaint. Total cohort included 78,186 patients (mean age, 53±19y, range, 14-89y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Item response theory (IRT) model assumptions of unidimensionality, local item independence, item fit, and presence of differential item functioning (DIF) were studied. LEPF-CAT- and LEPF-SF-generated scores were evaluated. RESULTS: An 18-item solution was supported for its unidimensionality and fit to the IRT model, with reliability estimates >0.9 for all administration modes. No DIF impact on LEPF scores was identified. Scores discriminated between multiple patient groups in clinically logical ways and were highly responsive to change, with negligible floor or ceiling effects. CAT scores were generated using an average of 4.9 items (median, 4). CONCLUSIONS: The LEPF scores were reliable, valid, and efficient for assessing perceived physical function of patients with musculoskeletal impairments of the hip, knee, foot, and ankle; thus, it was found suitable for research and routine clinical administration. These findings are limited to the type of patients included in this study, with further validation needed to assess their generalizability.

Development of a Multidimensional, Multigroup Measure of Self-Care for Inpatient Rehabilitation.

OBJECTIVE: To develop and evaluate a measure of clinician-observed and patient-performed self-care function for use during inpatient rehabilitation. DESIGN: Retrospective analysis of self-care assessments collected by therapists using confirmatory factor analysis (CFA) followed by multidimensional item response theory (MIRT). SETTING: Freestanding inpatient rehabilitation hospital in the Midwestern United States. PARTICIPANTS: Inpatients (N=7719) with stroke, traumatic brain injury, spinal cord injury, neurologic disorders, and musculoskeletal conditions. INTERVENTIONS: Not applicable MAIN OUTCOME MEASURES: A total of 19 clinician-selected self-care measures including the FIM and patient-performed, clinician-rated measures of balance, upper extremity function, strength, changing body position, and swallowing. Clinicians completed assessments on admission and at least 1 interim assessment. RESULTS: CFA was completed for 3 patient groups defined by their highest level of balance (sitting, standing, walking). We reduced the number of items by 47.5% while maintaining acceptable internal consistency; unidimensionality within each item set required development of testlets. A recursive analysis defined a self-care measure with sensitivity (Cohen dmax-min =1.13; Cohen dlast-first.=0.91) greater than the FIM self-care items (dmax-min.=0.94; dlast-first .=0.83). The CFA models provided good to acceptable fit (root mean square error of approximations 0.03-0.06). Most patients with admission FIM self-care ratings of total assistance (88%, 297 of 338) made improvements on the MIRT self-care measure that were undetected by the FIM; the FIM detected no change for 26% of these patients (78 of 297). The remaining 74% (219 of 297) improved on the MIRT-based measure an average of 14 days earlier than was detected by the FIM. CONCLUSIONS: This MIRT self-care measure possesses measurement properties that are superior to the FIM, particularly for patients near its floor or ceiling. Methods assure accommodation for multidimensionality and high levels of sensitivity. This self-care measure has the potential to improve monitoring of self-care and manage therapy effectively during inpatient rehabilitation.

The effectiveness of diacutaneous fibrolysis on pain, range of motion and functionality in musculoskeletal disorders: A systematic review and meta-analysis.

OBJECTIVE: To assess the effectiveness of diacutaneous fibrolysis in reducing musculoskeletal disorders symptoms such as pain, range of motion and functionality. DATA SOURCES: A systematic review of MEDLINE, Cochrane, PEDro and Science Direct was conducted until September 2020. REVIEW METHODS: Computerized search strategy was performed to identify randomized controlled trials applying diacutaneous fibrolysis, on subjects with musculoskeletal disorders. Eligible articles and data extraction were conducted independently by two reviewers. Methodology quality and risk of bias were assessed by Risk of Bias 2 tool from the Cochrane Collaboration and Physiotherapy Evidence Database. Outcomes assessed were pain intensity, range of motion and functionality. RESULTS: Search strategy identified 98 potential randomized control trials and six studies involving 386 participants, were finally included. Diacutaneous fibrolysis intervention added to usual physiotherapy treatment was compared to control group. Pain intensity immediately after treatment showed a pooled Standard Mean Difference (SMD) of -0.58 with 95% confidence interval (CI) from -1.12 to -0.04, and in the longest follow-up SMD was -0.63 with 95% CI (-1.21 to -0.05). Functionality showed a pooled SMD of -1.02 with 95% CI (-1.67 to -0.36) immediately after intervention and a SMD of -0.84 with 95% CI (-1.54 to -0.14). Range of motion could not be included in the quantitative synthesis. CONCLUSION: Diacutaneous fibrolysis is an effective treatment, when combined with conventional physiotheraphy, reducing pain immediately after treatment and long term follow-up and improving function in both, short and long term in musculoskeletal disorders.

A quality indicator set for rehabilitation services for people with rheumatic and musculoskeletal diseases demonstrates adequate responsiveness in a pre-post evaluation.

BACKGROUND: Quality of care is gaining increasing attention in research, clinical practice, and health care planning. Methods for quality assessment and monitoring, such as quality indicators (QIs), are needed to ensure health services in line with norms and recommendations. The aim of this study was to assess the responsiveness of a newly developed QI set for rehabiliation for people with rheumatic and musculoskeletal diseases (RMDs). METHODS: We used two yes/no questionnaires to measure quality from both the provider and patient perspectives, scored in a range of 0-100% (best score, 100%). We collected QI data from a multicenter stepped-wedge cluster-randomized controlled trial (the BRIDGE trial) that compared traditional rehabilitation with a new BRIDGE program designed to improve quality and continuity in rehabilitation. Assessment of the responsiveness was performed as a pre-post evaluation: Providers at rehabilitation centers in Norway completed the center-reported QIs (n = 19 structure indicators) before (T1) and 6-8 weeks after (T2) adding the BRIDGE intervention. The patient-reported QIs comprised 14 process and outcomes indicators, measuring quality in health services from the patient perspective. Pre-intervention patient-reported data were collected from patients participating in the traditional program (T1), and post-intervention data were collected from patients participating in the BRIDGE program (T2). The patient groups were comparable. We used a construct approach, with a priori hypotheses regarding the expected direction and magnitude of PR changes between T1 and T2. For acceptable responsivess, at least 75% of the hypotheses needed to be confirmed. RESULTS: All eight participating centers and 82% of the patients (293/357) completed the QI questionnaires. Responsiveness was acceptable, with 44 of 53 hypotheses (83%) confirmed for single indicators and 3 of 4 hypotheses (75%) confirmed for the sum scores. CONCLUSION: We found this QI set for rehabilitation to be responsive when applied in rehabilitation services for adults with various RMD conditions. We recommend this QI set as a timely method for establishing quality-of-rehabilitation benchmarks, promoting important progress toward high-quality rehabilitation, and tracking trends over time. TRIAL REGISTRATION: The study is part of the larger BRIDGE trial, registered at ClinicalTrials.gov (Identifier: NCT03102814).

Physical activity after inpatient occupational rehabilitation: Secondary outcomes of two randomized controlled trials.

OBJECTIVES: To assess whether inpatient multicomponent occupational rehabilitation, including physical activity (PA), increases the PA level of participants more than an outpatient program without PA, and whether changes in PA are associated with future work outcomes. METHODS: A total of 265 participants were included in one of two randomized clinical trials. Participants had been sick listed 2-12 months with a musculo-skeletal, psychological, or general/unspecified diagnosis. We measured PA by questionnaires at the start of the programs and at 3, 6, and 12 months of follow-up. Between-group differences in PA were assessed using linear mixed models. Associations between change in PA and future work outcomes were assessed by logistic and linear regression. RESULTS: There was no difference in change in PA between the inpatient and outpatient programs during 12 months of follow-up. We did not find any associations between the amount of PA and future work outcomes. However, intensity of PA was positively associated with return to work (RTW); participants reporting increased vigorous PA had an odds ratio (OR) for RTW of 4.1 (95% confidence interval [CI] 1.1-15.7) whereas participants reporting consistently high intensity of PA had an OR of 3.1 (95% CI 1.0-9.7), compared to participants reporting low-intensity PA. CONCLUSION: Inpatient occupational rehabilitation, including PA, did not increase PA-level in the follow-up period more than a less comprehensive program without PA. The amount of PA was not associated with future work outcomes. However, vigorous PA showed a positive association with RTW.

Predictive validity of a customized functional capacity evaluation in patients with musculoskeletal disorders.

PURPOSE: To examine whether the performance-based work-related functional capacity evaluation (German title: Einschätzung körperlicher Leistungsfähigkeiten bei arbeitsbezogenen Aktivitäten-ELA) can predict return to work (RTW) in patients with musculoskeletal disorders (MSD). METHODS: A multicenter cohort study was conducted on 162 employed or self-employed patients with various injury-related and chronic MSD, recruited from four outpatient rehabilitation clinics. Patient-reported data on health and work ability were collected at discharge. The FCE test was performed subsequently. The overall FCE-based estimation of the ability to cope with the physical demands of work (positive vs. negative) was used to predict RTW. Successful RTW was defined as a combination of (self-)employment at the 3-month follow-up and a low level of sick leave (< 1.5 weeks) due to MSD. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated using logistic regression models to evaluate the predictive validity of the adjusted FCE results. RESULTS: Based on the FCE test, 82% of the patients were estimated as being able to cope with the physical demands of work. 77% of the patients with a positive FCE outcome returned to work (positive predictive value) and 83% with a negative FCE outcome did not (negative predictive value). Patients whose functional capacity was estimated to match the job demands were associated with sixfold higher odds of returning to work after adjusting for patient-reported data on health and work ability. The agreement between the FCE result and RTW differed only on a low to moderate level between the therapists who administered the FCE (72-89%). CONCLUSION: The FCE test at discharge predicts RTW among patients with musculoskeletal disorders.

The influence and added value of a Standardized Assessment and Reporting System for functioning outcomes upon national rehabilitation quality reports.

OBJECTIVE: To demonstrate the influence and added value of a Standardized Assessment and Reporting System (StARS) upon the reporting of functioning outcomes for national rehabilitation quality reports. A StARS builds upon an ICF-based (International Classification of Functioning, Disability and Health) and interval-scaled common metric. DESIGN: Comparison of current ordinal-scaled Swiss national rehabilitation outcome reports including an expert-consensus-based transformation scale with StARS-based reports through descriptive statistical methods and content exploration of further development areas of the reports with relevant ICF Core Sets. SETTING: Swiss national public rehabilitation outcome quality reports on the clinic level. PARTICIPANTS: A total of 29 Swiss rehabilitation clinics provided their quality report datasets including 18 047 patients. INTERVENTIONS: Neurological or musculoskeletal rehabilitation. MAIN OUTCOME MEASURES: Functional Independence Measure™ or Extended Barthel Index. RESULTS: Outcomes reported with a StARS tended to be smaller but more precise than in the current ordinal-scaled reports, indicating an overestimation of achieved outcomes in the latter. The comparison of the common metric's content with ICF Core Sets suggests to include 'energy and drive functions' or 'maintaining a basic body position' to enhance the content of functioning as an indicator. CONCLUSIONS: A StARS supports the comparison of outcomes assessed with different measures on the same interval-scaled ICF-based common metric. Careful consideration is needed whether an ordinal-scaled or interval-scaled reporting system is applied as the magnitude and precision of reported outcomes is influenced. The StARS' ICF basis brings an added value by informing further development of functioning as a relevant indicator for national outcome quality reports in rehabilitation.

Does a Patient's Approach to Achieving Goals Influence His or Her Recovery Trajectory After Musculoskeletal Illness?

BACKGROUND: The regulatory focus theory posits that, in general, people tend to be predominantly "promotion focused" or "prevention focused", and each individual's values and motivations influence which approach he or she may use when pursuing personal goals. People who are primarily promotion focused mostly see goals as opportunities to gain or advance (that is, play to win); people who are prevention focused mostly see goals as opportunities to stay safe (that is, play not to lose). Understanding the role of regulatory focus in the recovery of patients with orthopaedic conditions could provide novel insight into how surgeons can best communicate with patients to improve how they recover from illness or injury. QUESTION/PURPOSE: Are improvements in pain intensity and disability over 6 months associated with a patient's levels of promotion focus or prevention focus? METHODS: In this longitudinal observational study, we enrolled 144 patients with an upper extremity orthopaedic illness at a tertiary teaching hospital and followed them for 6 months. At baseline, patients completed validated self-reported measures of regulatory focus (Regulatory Focus Questionnaire), pain (Numerical Rating Scale), disability (the QuickDASH), and demographics. Assessments were repeated 6 months later, with 76% (110 of 144) of patients completing follow-up assessments. We examined whether regulatory focus was associated with recovery outcomes (level of pain and disability at 6 months). The patient's regulatory focus was graded as two numerical scores on separate promotion-focus and prevention-focus continuums. Each individual received a score on promotion focus and one on prevention focus.. RESULTS: An individual's level of promotion (ΔR = 0.021; p = 0.03; small effect size), but not his or her level of prevention (ΔR = 0.003; p = 0.35; negligible effect size), was associated with improvement in disability over a 6-month period (R = 0.61; p < 0.001). Patients with high promotion (n = 20, b = 0.284; p = 0.001) had the greatest improvements in disability after 6 months compared with patients with moderate (n = 73, b = 0.422; p < 0.001) or low (n = 17, b = 0.561; p < 0.001) promotion. The levels of promotion (b = -0.22; p = 0.09) and prevention (b = -0.04; p = 0.65) were not associated with pain over time. CONCLUSIONS: To support improvements in disability for patients with upper extremity orthopaedic conditions, surgeons' communication strategies, including explanations of diagnoses and recovery trajectories, should focus on increasing patients' level of promotion (for example, by emphasizing gains and promoting positive thinking), rather than prevention (for example, by providing reassurance and problem-solving what might go wrong). LEVEL OF EVIDENCE: Level II, prognostic study.