Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain

Abstract

Purpose: The present study aimed to identify predictors of rehabilitation outcome for patients with chronic musculoskeletal pain (CMP) and psychological problems. Methods: A retrospective cohort study including 230 adult patients with CMP admitted for multidisciplinary pain rehabilitation. Potential predictors were patient characteristics, duration of complaints, baseline functioning, pain, personality, coping style, fear of movement, psychological distress and type of treatment. Outcome measures were physical functioning, mental health, pain and patient-reported effect. Multiple (logistic) regression models were used to identify predictors. Results: Patients who were more disabled and patients with more pain benefitted more from the rehabilitation treatment than less disabled patients or those with less pain. Age, work status, vitality, depression and coping style also predicted outcomes significantly. The models explained between 27 and 80% of the outcomes. There was an interaction between type of treatment, work status and the baseline pain score as regards the outcome in terms of pain. Conclusions: No strong predictors of treatment outcome were found other than the baseline scores of the respective outcome variables. More disabled patients and patients with more pain benefitted more from the rehabilitation program. Other predictors improved the prediction models slightly.

• Implications for Rehabilitation

• It remains challenging to correctly predict the outcome of treatment from patients’ baseline sociodemographic and psychological characteristics; predictors other than baseline scores of the outcome variables are only slightly associated with treatment outcome.

• Patients with chronic musculoskeletal pain and poor physical functioning or mental health benefit most from pain rehabilitation.

• Older patients benefit less from a pain rehabilitation program than younger patients in terms of physical functioning.

• Pain reduction during a pain rehabilitation program is greatest in patients with high pain intensity who are not at work at the start of the rehabilitation program.

• Coping style influences the outcome of rehabilitation of patients with chronic musculoskeletal pain.

     

Factors promoting staying at work in people with chronic nonspecific musculoskeletal pain: A systematic review

Purpose: To identify determinants for staying at work (SAW) in workers with chronic musculoskeletal pain (CMP). Method: A systematic review of factors that promote SAW in workers with CMP. We searched the databases of PubMed, EMBASE, PsycInfo, CINAHL and the Cochrane Library. We included studies reporting on working subjects without present CMP-related sick leave. A quality assessment of GRADE criteria and evidence synthesis was performed. Results: We identified five cross-sectional studies and two qualitative studies reporting on factors associated with SAW in workers with CMP. Consistent association with SAW was found for low perceived physical disability and low emotional distress (low-level evidence). Duration of pain, catastrophizing, self-esteem and marital status were not associated with SAW (low-level evidence). Qualitative studies indicated that personal adjustments and workplace interventions are important determinants for SAW (evidence not graded). Conclusions: No high-level evidence for SAW determinants for workers with CMP was identified. Future interventions aimed at promoting SAW could consider reducing perceived physical disability and emotional distress, and promoting adjustment latitude at work, support from supervisors, and the workers’ motivation and self-management skills. Further research is required because knowledge of SAW in workers with CMP is scarce, and the relevance of the subject is high.

Implications for Rehabilitation

• When modifiable factors that promote staying at work can be identified, interventions can be developed to support the ability of workers with chronic nonspecific musculoskeletal pain to stay at work.

• Consistent evidence of promoting staying at work was found for low emotional distress and perceived physical disability, while duration of pain, catastrophizing, self-esteem and marital status were consistently not associated.

• Future interventions aimed at promoting staying at work should consider reducing perceived physical disability and emotional distress.

     

Nature and the natural environment as health facilitators: the need to reconceptualize the ICF environmental factors

Purpose: This work examines the environmental factors component of the International Classification of Functioning, Disability, and Health (ICF) relative to current health-facilitating evidence about natural environmental factors. We argue that the environmental factors component warrants reconceptualization in order to offer an extended and more systematic framework for identifying and measuring health-facilitating natural environmental factors. Method: Current evidence highlighting the potential health-facilitating benefits of natural environmental factors is synthesized and considered in the context of the ICF framework and its coding system. Results: In its current form, the ICF’s conceptual framework and coding system are inadequate for identifying and measuring natural environmental factors in individuals and groups with and/or without health conditions. Conclusion: The ICF provides an advanced framework for health and disability that reflects contemporary conceptualizations about health. However, given the scope of emerging evidence highlighting positive health and well-being outcomes associated with natural environmental factors, we believe the environmental factors component requires further advancement to reflect this current knowledge. Reconceptualizing the environmental factors component supports a more holistic interpretation of the continuum of environmental factors as both facilitators and barriers. In doing so, it strengthens the ICF’s utility in identifying and measuring health-facilitating natural environmental factors.

Implications for Rehabilitation

• Natural environmental factors constitute salient features of the environment with implications to health and disability, not simply aesthetic qualities.

• Fostering contact with nature and the natural environment may provide opportunities for respite and promote health benefits for individuals who experience a range of disability.

• Positive human-nature-health relationships may contribute to the maintenance and promotion of health at the population level.

     

Psychometric properties of the performing arts module of the Disabilities of the Arm,Shoulder, and Hand questionnaire

Abstract

Background: The Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) offers an optional performing arts module. The goal was to examine the psychometric properties of this module in musicians.

Methods: This study is a secondary analysis of a randomized controlled trial on the effectiveness of a biopsychosocial intervention to prevent or reduce playing-related disability in conservatory students. Baseline data were used to examine internal consistency and discriminative validity of the performing arts module of the DASH questionnaire. Construct validity was analyzed by hypotheses testing. The performing arts module outcomes were compared to scores from the general DASH questionnaire, pain disability index, Short-Form 36, playing-related musculoskeletal disorder (PRMD) intensity, and pain intensity.

Results: Questionnaires completed by 130 conservatory students were analyzed, 55% of the population was female. Median age was 20 years (IQR 4). The performing arts module showed good internal consistency (Cronbach’s alpha 0.893). Discriminative validity between students with and without PRMDs was good. Three out of six hypotheses were accepted, indicating moderate construct validity.

Conclusions: The performing arts module showed good internal consistency, good discriminative validity and moderate construct validity in a population of conservatory students.

• Implications for Rehabilitation

• Musicians suffer frequently from musculoskeletal disorders, mostly in the upper extremity.

• The Disabilities of the Arm, Shoulder, and Hand questionnaire is a well-known outcome measure, which also includes a performing arts module.

• This study is the first to explore psychometric properties of the performing arts module.

• The performing arts module of the Disabilities of the Arm, Shoulder, and Hand questionnaire showed good internal consistency, good discriminative validity, and moderate construct validity.

     

The relationship of severe health disorders with bone loss,grip strength,and mobility in postmenopausal women – a 15-year follow-up study

Purpose: To investigate the relationships of severe health disorders (SHD) with bone loss, grip strength (GS) and mobility in postmenopausal women. Method: The study sample consisted of 2227 Finnish women (mean age 53.2) from the Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) cohort. Postal inquiries and clinical measurements were completed during the 15-year follow-up at 5-year intervals between 1989 and 2004. Femoral neck bone mineral density (BMD) and GS were measured. Life-style factors and mobility were obtained via postal inquiries. Work disability pension according to the ICD-9 was an indicator of a SHD. Results: At the baseline 242 women had SHD, 506 got late SHD during 1989–1995, whereas 1479 women had none until 1996. The women with baseline SHD had higher annual bone loss (0.44%) than those without SHD (0.34%) (p?Conclusion: Effects of SHDs on BMD, GS, and mobility are disease-specific. Thus, rehabilitation should be encouraged in postmenopausal women with SHD, especially in case of diseases of respiratory and nervous system.

• Implications for Rehabilitation

• Osteoporosis, muscle strength and co-morbidity

• Women with severe health disorders (SHD) leading to work disability have impaired musculoskeletal health.

• Active monitoring of the musculoskeletal health is advised for those with SHD.

• Women with SHD may benefit from rehabilitative treatment in order to avoid complications of musculoskeletal impairments.

     

Spinal cord injury (SCI) rehabilitation: systematic analysis of communication from the biopsychosocial perspective

Abstract

Purpose: Communication is powerful predictor of health-related quality of life and overall well-being, yet its role in promoting rehabilitation outcomes in spinal cord injury (SCI) is rarely mentioned. This article systematically analyzes and synthesizes literature from multiple disciplines according to a biopsychosocial perspective, providing an evidence base for clinical practice and clear direction for future research. Method: Systematic literature review and analysis, incorporating mapping to International Classification of Functioning, Disability and Health (ICF) codes. Results: In total 4338 entries were retrieved from CINAHL, PsychInfo, Medline, PubMed and SpeechBite databases for the period 1990–2014. A total of 115 treatment and observational studies (quantitative and qualitative) detailed aspects of communication according to structure, function, activity, participation and environmental factors; evident of the complex interactions between communicative function with daily living after SCI. Conclusions: Communication is a relative strength in SCI, key to empowerment, independence, social interaction, and well-being, yet its potential to enhance SCI rehabilitation outcomes remains largely underexplored and untapped. Through elucidating interactions between communication and functioning, the adapted ICF framework affords clinicians and researchers insight into areas of intervention most likely to result in widespread gains. Conscious consideration should be given to the role of communication, within an integrative, strengths-based, multidisciplinary approach to clinical practice and future research.

• Implications for Rehabilitation

• Communication fosters empowerment, independence and greater participation in life roles; recognized as a powerful predictor of health-related quality of life and overall well-being.

• The ICF framework elucidates influences to communicative function, and components which are influenced by communication, providing valuable insight for clinicians and researchers.

• Therapeutic and research endeavors guided by existing ICF core sets are at risk of failing to consider communication, thereby limiting rehabilitation outcomes.

• Tapping the potential of communication as a relative strength within SCI rehabilitation holds considerable promise, within integrative, strengths-based, multidisciplinary approaches to clinical practice and future research.

     

Genetic and ethnic modulation of cardiovascular toxicity of vascular endothelial growth factor inhibitors

Vascular endothelial growth factor (VEGF) inhibitors, including monoclonal antibodies and tyrosine kinase inhibitors (TKIs), are important as anticancer treatments through curbing tumour angiogenesis and growth. VEGF inhibitors have significant cardiovascular effects. By blocking VEGF receptors, ligands, or signal pathways, VEGF inhibitors disturb the balance between vasodilation and vasoconstriction, undermine endothelial cell integrity, and activate cardiomyocyte apoptosis. VEGF inhibitors increase risks of hypertension, heart failure, thromboembolism and arrhythmia. Genetic and geographic studies showed that genetic polymorphisms likely play significant predictive or prognostic roles in cardiovascular toxicity associated with VEGF inhibitors. This review updates current understandings of VEGF inhibitors on cardiovascular toxicity, explores potential mechanisms, and clarifies whether genetic or ethnic factors contribute to their adverse effects.

• Key Messages

• VEGF inhibitors disturb the balance between vasodilation and vasoconstriction, undermine endothelial cell integrity and activate cardiomyocyte apoptosis.

• VEGF inhibitors increase risks of hypertension, heart failure, thromboembolism and arrhythmia.

• Genetic and geographic studies showed that genetic polymorphisms likely play significant predictive or prognostic roles in cardiovascular toxicity associated with VEGF inhibitors.

     

An overview of systematic reviews of adaptive seating interventions for children with cerebral palsy: where do we go from here?

Purpose: This article provides an overview and assessment of systematic reviews of adaptive seating outcomes in children with cerebral palsy (CP) and proposes strategies to advance and improve the clinical utility of future research evidence. Methods: A comprehensive search for systematic reviews was performed to locate and evaluate the functional effects of adaptive seating in children with CP. Relevant electronic databases were searched to identify reviews published between January 1990 and December 2010. Results: The search yielded five reviews of adaptive seating interventions that found generally positive, but inconclusive evidence of effectiveness for postural control and management, seated posture, upper extremity function, and overall clinical outcomes. Review authors consistently reported that they were unable to combine data from original research studies to make sound clinical recommendations due to the low quality of studies, the lack of appropriate outcome indicators, and the heterogeneity and lack of clarity in population characteristics and adaptive seating interventions. Conclusions: Strategies to improve the quality and clinical relevance of new research evidence for adaptive seating interventions include the adoption of an expanded view of child functioning, a child motor function classification and development approach, and contemporary frameworks for the measurement and evaluation of assistive technology outcomes.

Implications for Rehabilitation

• Assistive technology practitioners recommend adaptive seating devices to improve child functioning.

• Past systematic reviews of adaptive seating outcomes in children with cerebral palsy provide limited empirical support.

• Current thinking about child health and assistive technology outcomes provides direction to inform research and clinical practice.

     

Determinants for lumbopelvic pain 6 months postpartum

Purpose: To evaluate potential determinants of self-reported lumbopelvic pain 6 months postpartum for pregnant women with and without lumbopelvic pain. Methods: Questionnaires were answered in weeks 19–21 of pregnancy and at 6 months postpartum. The Pain Catastrophizing Scale was used to assess exaggerated negative thoughts about pain experiences, the Fear-Avoidance Beliefs Questionnaire to assess beliefs about how physical activity affects back pain, the Visual Analogue Scale to assess pain intensity, the Disability Rating Index to assess physical ability, and the Nottingham Health Profile to assess health-related quality of life. A Cox proportional hazards model was used to analyse the data. Results: Of the 273 women who answered at both occasions, 112 had lumbopelvic pain in pregnancy and 161 did not. For pregnant women with lumbopelvic pain a higher level of catastrophizing and a more restricted physical ability both doubled the risk for postpartum lumbopelvic pain. Conclusions: We conclude that catastrophizing and physical ability, in weeks 19–21 of pregnancy determine postpartum lumbopelvic pain, and hence that, women at risk might be identified by the use of a biopsychosocial approach in pregnancy. It seems important to take these results into consideration both when forming preventive strategies and in rehabilitation.

Implications for Rehabilitation

• A high level of catastrophizing and a low physical ability in women with lumbopelvic pain during pregnancy increased the risk of reporting postpartum lumbopelvic pain.

• A biopsychosocial approach during pregnancy seems important for to identify women at risk for future pain.

• Interventions targeting catastrophizing might have a positive effect but that needs to be studied for this specific population.

     

“It is about taking grips and not let myself be ravaged by my body”: A qualitative study of outcomes from in-patient multidisciplinary rehabilitation for patients with chronic rheumatic diseases

Purpose: To explore how patients experience the process and personal impact of deriving outcomes from a rheumatological rehabilitation program. Methods: Semi-structured interviews were conducted with 23 patients with inflammatory rheumatic diseases approximately 2 months after a 4-week hospital based multidisciplinary rehabilitation program. A thematic analysis was applied. Results: Overarching themes were increased dignity and self-respect. Initial uncertainty regarding illness management was exchanged with confident coping and of becoming an active agent in ones own life. Strategies and coping tools tried out during the rehabilitation stay, do by their experienced effect become primary sources of gained insight into illness and symptom manifestation. Both elements give a sense of control and influence self-confidence and motivation to engage in self-management. The process from gained insight and experienced effect of coping tools, to active self management, is however, not automatic. Psychological factors play a key role, and there is a need to take individual psychological themes into account and tailor interventions accordingly. Conclusions: Specialized multidisciplinary rehabilitation is an ongoing active process, in which psychological factors play a key role and must be accounted for. Well targeted rehabilitation has the potential to create outcomes of major personal impact.

Implications for Rehabilitation

• Well targeted multidisciplinary rehabilitation has the potential to create outcomes of major personal impact

• Rehabilitation interventions should be tailored according to the patient’s subjective perception of challenges.

• A secure and supportive environment where patients are met with respect and interest represents a crucial element in rehabilitation.

     

Technical devices in children with motor disabilities: a review

Abstract

Purpose: To assess the effectiveness of technical devices used in children with motor disabilities. Method: A systematic search of CINAHL Plus, EMBASE, PEDro, Cochrane Library, Isi Web of Knowledge and Scifinder Web was carried out, covering the period between January 2000 and January 2012. The inclusion criteria were: (1) Studies involving a minimum of five children (randomized-clinical trials with control group and experimental group, clinical trials without control group and prospective cohort studies; (2) age range, 0 to 18 years. The methodological quality of the included studies was assessed by the two authors through the application of the PEDro scale. Results: Of the 59 articles identified by the search strategy, 27 articles were considered eligible. The most frequently evaluated devices were ankle and foot orthoses and the most studied pathology was cerebral palsy. The mean score on the PEDro scale was 6.8. Conclusions: The methodological quality of studies needs to be improved and more rigorous research designs should be followed that will allow the effectiveness and quality of movement to be assessed. The satisfaction of the patient and family with the devices should be analyzed in future studies.

• Implications for Rehabiliation

• The study adds an analysis of studies to determine the effectiveness of technical devices in children with motor disabilities and proposals for future studies to assess the long-term outcomes and improve the quality of interventions.

• Therefore, this review proposes to identify:

• The main technical device used in children with motor disability.

• Which types of pathology or motor disorders require technical devices to be used and what devices are available.

• The effects on the child of wearing technical devices.

• The measurements used to determine the effectiveness of technical aids.

     

The relation of social support and depression in patients with chronic low back pain

Purpose: Depression is a common condition in adults with low back pain (LBP), and is associated with poorer patient outcomes. Social support is a modifiable factor that may influence depressive symptoms in people with LBP and, if so, could be a consideration in LBP management when depression is an issue. The aim of this study was to examine social support as a prognostic factor for depressive symptoms and recovery from depression in patients with LBP.

Method: Patients with LBP (n?=?483), recruited from four imaging centers in Canada, completed an initial survey following imaging and a follow-up survey one year later, including the Medical Outcomes Study (MOS) Social Support Survey and the Center for Epidemiologic Studies Depression Scale. Multivariable regression analyses were used to examine the relationship between social support and depression.

Results: More social support (overall functional social support) at baseline was associated with recovery from depression (OR?=?0.24; 95% CI 0.10, 0.55) and less depressive symptoms (β?=?1.68; 95% CI?=?0.36, 3.00) at one-year follow-up. In addition, associations were found between specific aspects (subscales) of social support and the two depression outcomes.

Conclusions: Functional social support as a prognostic factor for depression and possible target of LBP management warrants further investigation.

• Implications for Rehabilitation

• Depression is a common condition in adults with low back pain (LBP), and is associated with poorer patient outcomes.

• This study provides evidence for social support as a prognostic factor for depressive symptoms and recovery from depression in patients with LBP problems.

• Management of pain conditions may be enhanced by a better understanding of modifiable risk factors for depression, such as social support.

     

The effectiveness of graded activity in patients with non-specific low-back pain: a systematic review

Background: Non-specific low-back pain (LBP) is considered a major health and economic problem in Western society. Nowadays a common used intervention on non-specific LBP is graded activity (GA). Graded Activity developed by Lindström et al., consisted of four parts: (i) measurements of functional capacity; (ii) a work-place visit; (iii) back school education and (iv) an individual, sub-maximal, gradually increased exercise program with an operant-conditioning behavioural approach as described by Fordyce et al. Objective: To evaluate the effectiveness of GA in adults with non-specific LBP on pain, disabilities and return to work. Data sources: An extensive literature search of PubMed, Embase, CINAHL and The Cochrane Library was conducted in July 2011. Review Methods: Randomized controlled trials (RCTs) evaluating the effect of GA in patients with non-specific LBP were eligible. Methodological quality of the studies was assessed according to the PEDro scale. A best-evidence synthesis was conducted according to van Peppen et al. to interpret the outcomes of the included studies. Results: Ten articles were included in this systematic review; these articles described five RCTs (680 patients). The best-evidence synthesis revealed that there was no or insufficient evidence for a positive effect of GA on pain, disabilities and return to work in patients with non-specific LBP. Conclusion: Currently there is no or insufficient evidence that GA results in better outcomes of patients with non-specific LBP.

Implications for Rehabilitation

Graded Activity in non-specific low-back pain

• Non-specific low-back pain is not only a physical problem but can be influenced by patient’s beliefs, psychological distress and illness behaviour.

• In clinical practise the use of Graded Activity (GA) can be recommend when a discrepancy between musculoskeletal functioning and disabilities are present in a patient, for instance the presence of kinesiophobia.

• There is no or insufficient evidence that GA results in better outcomes than usual care.

     

Young adults with intellectual disability transitioning from school to post-school: A literature review framed within the ICF

Purpose: The purpose of this review was to describe literature relating to transition for young people with an intellectual disability and identify gaps within the current knowledge base. Method: A narrative literature review was undertaken. Searches of databases Medline, CINAHL, PsycINFO, ERIC, ISI Web of Science and ProQuest 500 International provided relevant research articles. The search terms used were intellectual disability, transition, employment, and ICF as well as other terms derived from the ICF. Manual searches of reference lists identified additional studies. Furthermore, government websites were searched for relevant reports and policies. Results: Transition literature was explored by ICF domains; body functions and structures, activity and participation and contextual factors. Studies were identified in some but not all areas and included literature describing self-determination and participation in leisure activities for those with mild intellectual disability. However, significant gaps were found particularly for those with severe intellectual disability. Conclusions: The ICF is a useful tool in framing a review of transition literature for young people with intellectual disability due to the complexity and multi-faceted nature of transition. The important influence of environmental factors including family systems, post-school services and access to transport were highlighted as having considerable impacts on transition outcomes.

Implications for Rehabilitation

• The ICF is a useful tool in framing transition research to identify gaps.

• The current body of literature in transition from school for young adults with intellectual disabilities is too singularly focused and rarely considers those with moderate to severe intellectual disability.

• There has been little research on this topic in low and middle income countries.

• The scale of the impact of environmental factors on young people transitioning from school to post-school is currently under-represented.

• A holistic approach to post-school outcomes needs to be undertaken in future research.

     

What does the literature say about using robots on children with disabilities?

Purpose: The purpose of this study is to examine the extent and type of robots used for the rehabilitation and education of children and young people with CP and ASD and the associated outcomes.

Methods: The scholarly literature was systematically searched and analyzed. Articles were included if they reported the results of robots used or intended to be used for the rehabilitation and education of children and young people with CP and ASD during play and educative and social interaction activities.

Results: We found 15 robotic systems reported in 34 studies that provided a low level of evidence. The outcomes were mainly for children with ASD interaction and who had a reduction in autistic behaviour, and for CP cognitive development, learning, and play.

Conclusion: More research is needed in this area using designs that provide higher validity. A centred design approach is needed for developing new low-cost robots for this population.

• Implications for rehabilitation

• In spite of the potential of robots to promote development in children with ASD and CP, the limited available evidence requires researchers to conduct studies with higher validity.

• The low level of evidence plus the need for specialized technical support should be considered critical factors before making the decision to purchase robots for use in treatment for children with CP and ASD.

• A user-entered design approach would increase the chances of success for robots to improve functional, learning, and educative outcomes in children with ASD and CP. We recommend that developers use this approach.

• The participation of interdisciplinary teams in the design, development, and implementation of new robotic systems is of extra value.

• We recommend the design and development of low-cost robotic systems to make robots more affordable.

     

The relationship between pain,disability, quality of life and cognitive-behavioural factors in chronic back pain

Purpose: This pilot study systematically examined the correlations between the outcome variables pain intensity, disability and health-related quality of life (HRQOL) and between these outcomes and known psychological risk factors for chronic low back pain (CLBP), such as depression, trait anxiety, avoidance- and endurance-related pain responses at two different assessment points. Method: Data from 52 CLBP inpatients treated in an orthopedic clinic were investigated at two points in time: during the first days after admission and 6 months after the termination of the inpatient treatment. Bivariate relationships between pain intensity, disability, HRQOL and psychological variables were examined with the help of Pearson product moment correlations. Furthermore, the differences that exist between correlations at baseline and follow-up were tested for significance. Results: Significant and large differences were found between the correlations with low correlations at baseline and high correlations at the follow-up. Furthermore, HRQOL showed a positive correlation with endurance-related and a negative correlation with avoidance-related pain responses. Conclusions: Focusing on a systematic comparison of two significant assessment time points in CLBP with an acute exacerbation at baseline, the results of this study underlined the recurrent course of LBP. The results highlight that the assessment time points play an important role in CLBP.

Implications for Rehabilitation

• Low back pain is a major public health problem with high direct and indirect back-pain-related costs.

• Chronic low back pain is a disabling disease which restricts quality of life.

• Psychological factors may have a larger impact on disability and quality of life than pain itself.

• The recurrent course of low back pain highlights the importance of multidisciplinary pain management even during acute exacerbations of pain.