Correlates of Objectively Measured Physical Activity Among People With Multiple Sclerosis: A Cross-Sectional Study.

Background: Identifying correlates of physical activity (PA) for people with multiple sclerosis (MS) is essential to design effective PA interventions. Methods: Participants completed a battery of questionnaires and wore an ActiGraph accelerometer. Light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) (min/day) were calculated. Associations were examined using multiple linear regression adjusted for demographic and clinical confounders. Results: Fifty-eight adults with MS participated (mean ± SD age: 56.8 ± 9.2 yr; 67% women). MS type was associated with time in LPA. Participants with secondary progressive MS (B = -54.0, 95% CI -84.7 to -23.3) and primary progressive MS (B = -42.9, 95% CI -77.5 to -8.3) spent less time in LPA than those with relapsing remitting MS. Walking capacity, assessed using the 12-item MS walking scale (MSWS-12), was associated with time in MVPA (B = -0.36, 95% CI -0.72 to -0.01). Conclusion: This work identifies walking capacity and type of MS as correlates of PA, which may indicate development of interventions to promote PA.

Safety, feasibility, acceptability and effects of a behaviour-change intervention to change physical activity behaviour among people with multiple sclerosis: Results from the iStep-MS randomised controlled trial.

BACKGROUND: There is limited information regarding the safety, feasibility and acceptability of behaviour-change interventions to increase physical activity (PA) and reduce sedentary behaviour among people with multiple sclerosis (MS). Prior to evaluating efficacy, it is important to identify problems with feasibility and acceptability, which may undermine effectiveness. OBJECTIVE: To examine the safety, feasibility and acceptability of a behaviour-change intervention to increase PA and reduce sedentary behaviour among people with MS. METHODS: Sixty people received a 3-month intervention or usual care. Fatigue, pain and adverse events (AEs) were assessed. Feasibility and acceptability were explored through focus groups with physiotherapists and interviews with participants. Fidelity to intervention content, delivery skills, programme receipt and programme task were assessed. RESULTS: There was no difference in AE rate between groups (p = 0.965). Fatigue and pain were not higher in the intervention group at 3 or 9 months. Therapists reported the intervention was feasible to deliver and fidelity was acceptable. Twenty-nine participants (97%) attended at least 75% of sessions. Participants found the intervention acceptable but suggested some amendments were required to intervention components. CONCLUSIONS: The intervention was safe, feasible and acceptable. Although modifications are required to intervention components, the intervention warrants further evaluation in a future trial.

Non-invasive brain stimulation techniques for chronic pain.

BACKGROUND: This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE). OBJECTIVES: To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain. SEARCH METHODS: For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017. SELECTION CRITERIA: Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables. MAIN RESULTS: We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events. AUTHORS' CONCLUSIONS: There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.

Non-invasive brain stimulation techniques for chronic pain.

BACKGROUND: This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE). OBJECTIVES: To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain. SEARCH METHODS: For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017. SELECTION CRITERIA: Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables. MAIN RESULTS: We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events. AUTHORS' CONCLUSIONS: There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.

Changing physical activity behaviour for people with multiple sclerosis: protocol of a randomised controlled feasibility trial (iStep-MS).

INTRODUCTION: Although physical activity may reduce disease burden, fatigue and disability, and improve quality of life among people with multiple sclerosis (MS), many people with MS are physically inactive and spend significant time in sedentary behaviour. Behaviour change interventions may assist people with MS to increase physical activity and reduce sedentary behaviour. However, few studies have investigated their effectiveness using objective measures of physical activity, particularly in the long term. Further, interventions that have proven effective in the short term may not be feasible in clinical practice because of the large amount of support provided. The iStep-MS trial aims to determine the safety, feasibility and acceptability of a behaviour change intervention to increase physical activity and reduce sedentary behaviour among people with MS. METHODS AND ANALYSIS: Sixty people with MS will be randomised (1:1 ratio) to receive a 12-week intervention or usual care only. The intervention consists of four physical activity consultations with a physiotherapist supported by a handbook and pedometer. Outcomes assessed at baseline, 12 weeks and 9 months are physical activity (ActiGraph wGT3X-BT accelerometer), sedentary behaviour (activPAL3µ), self-reported activity and sitting time, walking capability, fatigue, self-efficacy, participation, quality of life and health service use. The safety of the intervention will be determined by assessing change in pain and fatigue and the incidence of adverse events during the follow-up period. A parallel process evaluation will assess the feasibility and acceptability of the intervention through assessment of fidelity to the programme and semistructured interviews exploring participants' and therapists' experiences of the intervention. The feasibility of conducting an economic evaluation will be determined by collecting data on quality of life and resource use. ETHICS AND DISSEMINATION: Research ethics committee approval has been granted from Brunel University London. Results of the trial will be submitted for publication in journals and distributed to people with MS and physiotherapists. TRIAL REGISTRATION NUMBER: ISRCTN15343862 (doi 10.1186/ISRCTN15343862). Protocol version: 1.0; Pre-results.

Non-invasive brain stimulation techniques for chronic pain.

BACKGROUND: This is an updated version of the original Cochrane review published in 2010, Issue 9. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS) and reduced impedance non-invasive cortical electrostimulation (RINCE). OBJECTIVES: To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain. SEARCH METHODS: We searched CENTRAL (2013, Issue 6), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS and clinical trials registers. The original search for the review was run in November 2009 and searched all databases from their inception. To identify studies for inclusion in this update we searched from 2009 to July 2013. SELECTION CRITERIA: Randomised and quasi-randomised studies of rTMS, CES, tDCS or RINCE if they employed a sham stimulation control group, recruited patients over the age of 18 with pain of three months duration or more and measured pain as a primary outcome. DATA COLLECTION AND ANALYSIS: Two authors independently extracted and verified data. Where possible we entered data into meta-analyses. We excluded studies judged as being at high risk of bias from the analysis. We used the GRADE system to summarise the quality of evidence for core comparisons. MAIN RESULTS: We included an additional 23 trials (involving 773 participants randomised) in this update, making a total of 56 trials in the review (involving 1710 participants randomised). This update included a total of 30 rTMS studies, 11 CES, 14 tDCS and one study of RINCE(the original review included 19 rTMS, eight CES and six tDCS studies). We judged only three studies as being at low risk of bias across all criteria.Meta-analysis of studies of rTMS (involving 528 participants) demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective (low-quality evidence) and that rTMS applied to the dorsolateral prefrontal cortex is ineffective (very low-quality evidence). We found a short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies (low-quality evidence, standardised mean difference (SMD) 0.39 (95% confidence interval (CI) -0.27 to -0.51 P < 0.01)). This equates to a 12% (95% CI 8% to 15%) reduction in pain, which does not exceed the pre-established criteria for a minimal clinically important difference (≥ 15%). Evidence for multiple-dose studies was heterogenous but did not demonstrate a significant effect (very low-quality evidence).For CES (six studies, 270 participants) no statistically significant difference was found between active stimulation and sham (low-quality evidence).Analysis of tDCS studies (11 studies, 193 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation (very low-quality evidence). Pre-specified subgroup analysis of tDCS applied to the motor cortex (n = 183) did not demonstrate a statistically significant effect and this lack of effect was consistent for subgroups of single or multiple-dose studies.One small study (n = 91) at unclear risk of bias suggested a positive effect of RINCE over sham stimulation on pain (very low-quality evidence).Non-invasive brain stimulation appears to be frequently associated with minor and transient side effects, though there were two reported incidences of seizure related to active rTMS in the included studies. AUTHORS' CONCLUSIONS: Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. It is likely that multiple sources of bias may exaggerate this observed effect. The effects do not meet the predetermined threshold of minimal clinical significance and multiple-dose studies do not consistently demonstrate effectiveness. The available evidence suggests that low-frequency rTMS, rTMS applied to the pre-frontal cortex, CES and tDCS are not effective in the treatment of chronic pain. While the broad conclusions for rTMS and CES have not changed substantially, the addition of this new evidence and the application of the GRADE system has modified some of our interpretation and the conclusion regarding the effectiveness of tDCS has changed. We recommend that previous readers should re-read this update. There is a need for larger, rigorously designed studies, particularly of longer courses of stimulation. It is likely that future evidence may substantially impact upon the presented results.

Influence of a walking aid on temporal and spatial parameters of gait in healthy adults.

OBJECTIVE: To determine the effect of using a walking aid on temporal and spatial parameters of gait when used for balance versus support on the dominant and nondominant hand side. DESIGN: Repeated measures observational study design. SETTING: University gymnasium. PARTICIPANTS: Twenty-seven healthy male and female adults of mean ± standard deviation age 44.74 ± 10.00 years. METHODS: Five walking conditions (C) were completed by all participants on the GAITRite pressure mat. Normal walking (C1), walking with a cane in the dominant hand (C2) and nondominant hand (C3) as if using for balance, walking with a cane in the dominant hand (C4) and nondominant hand (C5) while allowing approximately 10% of the body weight through the cane. MAIN OUTCOME MEASUREMENTS: Temporal measurements (swing time, stance time, single limb support time, double limb support time) as percentage of a gait cycle and the base of support for the left and the right foot for all 5 walking conditions. RESULTS: A significant difference (P < .001) was observed between C1, C2, and C3 in percentage swing time and percentage stance time of the ipsilateral side, and in percentage single limb support time of the contralateral side. The double limb support time was significantly different (P ≤ .04) for both ipsilateral and contralateral sides. Comparisons among C1, C4, and C5 demonstrated significance (P < .001) for all variables. Post hoc analysis showed significance between C1 and C4, and C1 and C5 for all variables except percentage stance time of the ipsilateral side and percentage single limb support of the contralateral side. CONCLUSIONS: In healthy adults, use of a cane for balance modifies swing and stance parameters of the ipsilateral side and does not affect the base of support formed by the feet. When used for support, the cane alters the swing and stance parameters, and also the base of support formed by the feet.

The effect of core stability exercises on variations in acceleration of trunk movement, pain, and disability during an episode of acute nonspecific low back pain: a pilot clinical trial.

OBJECTIVE: The purpose of this preliminary study was demonstrate if it was feasible to evaluate variations in acceleration of trunk movement, pain, and disability during an episode of acute nonspecific low back pain comparing regular trunk exercises to regular exercises in addition to core stability exercises. METHODS: A pilot randomized controlled trial was used to evaluate 33 participants recruited from a National Health Service physiotherapy musculoskeletal provider in the London district of Hillingdon. Participants were allocated to 2 groups; a regular exercise group (male, 2; female, 15) with a mean (SD) age of 35.8 (9.1) years and intervention group (male, 3; female, 13) with a mean (SD) age of 36.2 (9.8) years. The regular exercise group received exercise that consisted of a core stability class including both specific and global trunk exercises. The intervention group, in addition to these core exercises, received further instruction on 8 specific stabilization muscles involving the transversus abdominis and the lumbar multifidus. Trunk sagittal acceleration, pain, and disability were measured using a Lumbar Motion Monitor, pain visual analog scale, and Roland Morris Disability Questionnaire, respectively. Measures were taken at baseline, 3 and 6 weeks, and a 3-month follow-up. Multiple regression with adjustment for baseline value was used to analyze each outcome. All outcomes were log transformed to correct skewness and so presented as ratio of geometric means with 95% confidence interval. RESULTS: Differences in mean trunk sagittal acceleration between the regular exercise and intervention groups was not statistically significant at any time point (ratio of means [95% confidence interval]: 3 weeks 1.2 [0.9-1.6], P = .2; 6 weeks 1.1 [0.8-1.5], P = .7; 3 months: 1.2 [0.8-1.9], P = .9). Similarly, the effects on neither pain score nor disability score were significant (pain score: 3 weeks 1.3 [0.8-2.2], P = .3); 6 weeks 1.2 [0.7-2.0], P = .6; 3 months 1.0 [0.5-1.9], P = 1.0); disability score: 6 weeks 1.0 [0.7-1.5], P = 1.0; 3 months 1.3 [0.8-1.9], P = .3). Outcome measures for both groups improved over time. CONCLUSIONS: This pilot study demonstrated that a study of this nature is feasible. Both the regular exercise and the intervention groups demonstrated improvements in mean trunk sagittal acceleration at 3, 6, and 12 weeks. The preliminary findings showed that evidence was inconclusive for the beneficial effect of adding specific core stability exercises for acute low back pain. The results of this study demonstrated an increase in acceleration accompanied by a reduction in pain, which may suggest that acute nonspecific low back pain may induce the pain-spasm-pain model rather than the pain adaptation model.

Non-invasive brain stimulation techniques for chronic pain.

BACKGROUND: Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES) and transcranial direct current stimulation (tDCS). OBJECTIVES: To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, the Cochrane PaPaS Group Trials Register and clinical trials registers. SELECTION CRITERIA: Randomised and quasi-randomised studies of rTMS, CES or tDCS if they employed a sham stimulation control group, recruited patients over the age of 18 with pain of three months duration or more and measured pain as a primary outcome. DATA COLLECTION AND ANALYSIS: Two authors independently extracted and verified data. Where possible we entered data into meta-analyses. We excluded studies judged as being at high risk of bias from the analysis. MAIN RESULTS: We included 33 trials in the review (involving 937 people)(19 rTMS, eight CES and six tDCS). Only one study was judged as being at low risk of bias.Studies of rTMS (involving 368 participants ) demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective. A short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies was suggested (standardised mean difference (SMD) -0.40, 95% confidence interval (CI) -0.26 to -0.54, P < 0.00001). This equates to a 15% (95% CI 10% to 20%) reduction in pain which does not clearly exceed the pre-established criteria for a minimally clinically important difference (> 15%).For CES (four studies, 133 participants) no statistically significant difference was found between active stimulation and sham. Analysis of tDCS studies (five studies, 83 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation. Pre-specified subgroup analysis of tDCS applied to the motor cortex suggested superiority of active stimulation over sham (SMD -0.59, 95% CI -1.10 to -0.08).Non-invasive brain stimulation appears to be associated with minor and transient side effects. AUTHORS' CONCLUSIONS: Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. The effects do not clearly exceed the predetermined threshold of minimal clinical significance. Low-frequency rTMS is not effective in the treatment of chronic pain. There is insufficient evidence from which to draw firm conclusions regarding the efficacy of CES or tDCS. The available evidence suggests that tDCS applied to the motor cortex may have short-term effects on chronic pain and that CES may be ineffective. There is a need for further, rigorously designed studies of all types of stimulation.

Self-reported assessment of disability and performance-based assessment of disability are influenced by different patient characteristics in acute low back pain.

For an individual, the functional consequences of an episode of low back pain is a key measure of their clinical status. Self-reported disability measures are commonly used to capture this component of the back pain experience. In non-acute low back pain there is some uncertainty of the validity of this approach. It appears that self-reported assessment of disability and direct measurements of functional status are only moderately related. In this cross-sectional study, we investigated this relationship in a sample of 94 acute low back pain patients. Both self-reported disability and a performance-based assessment of disability were assessed, along with extensive profiling of patient characteristics. Scale consistency of the performance-based assessment was investigated using Cronbach's alpha, the relationship between self-reported and performance-based assessment of disability was investigated using Pearson's correlation. The relationship between clinical profile and each of the disability measures were examined using Pearson's correlations and multivariate linear regression. Our results demonstrate that the battery of tests used are internally reliable (Cronbach's alpha = 0.86). We found only moderate correlations between the two disability measures (r = 0.471, p < 0.001). Self-reported disability was significantly correlated with symptom distribution, medication use, physical well-being, pain intensity, depression, somatic distress and anxiety. The only significant correlations with the performance-based measure were symptom distribution, physical well-being and pain intensity. In the multivariate analyses no psychological measure made a significant unique contribution to the prediction of the performance-based measure, whereas depression made a unique contribution to the prediction of the self-reported measure. Our results suggest that self-reported and performance-based assessments of disability are influenced by different patient characteristics. In particular, it appears self-reported measures of disability are more influenced by the patient's psychological status than performance-based measures of disability.

Reliability and validity of functional balance tests post stroke.

OBJECTIVE: To contribute to the reliability and validity of a series of functional balance tests for use post stroke. DESIGN: Within-session, test-retest and intertester reliability was tested using the kappa coefficient and intraclass correlations. The tests were performed three times and the first and third attempts compared to test the within-session reliability. The tests were repeated a few days later to assess test-retest reliability and were scored simultaneously by two physiotherapists to assess the intertester reliability. To test criterion-related validity the tests were compared with the sitting section of the Motor Assessment Scale, Berg Balance Scale and Rivermead Mobility Index using Spearman's rho. SETTING: Stroke physiotherapy services of six National Health Service hospitals. PARTICIPANTS: People with a post stroke hemiplegia attending physiotherapy who had no other pathology affecting their balance took part. Thirty-five people participated in the reliability testing and 48 people took part in the validity testing. MAIN OUTCOME MEASURES: The following functional balance tests were used: supported sitting balance, sitting arm raise, sitting forward reach, supported standing balance, standing arm raise, standing forward reach, static tandem standing, weight shift, timed 5-m walk with and without an aid, tap and step-up tests. RESULTS: The ordinal level tests (supported sitting and standing balance and static tandem standing tests) showed 100% agreement in all aspects of reliability. Intraclass correlations for the other tests ranged from 0.93 to 0.99. All the tests showed significant correlations with the appropriate comparator tests (r = 0.32-0.74 p < 0.05), except the weight shift test and step-up tests which did not form significant relationship with Berg Balance Scale (r = 0.26 and 0.19 respectively). CONCLUSION: These functional balance tests are reliable and valid measures of balance disability post stroke.

Development of the Brunel Balance Assessment: a new measure of balance disability post stroke.

OBJECTIVE: To report the psychometric properties of the Brunel Balance Assessment (BBA), a new test of balance disability post stroke. DESIGN: Data from 92 subjects were collected and cohorts used to test hierarchical scaling, reliability and validity. Data from 80 people were used to test the hierarchical scaling using an inter-item correlation for redundancy, coefficient of reproducibility (CR) and scalability (CS) for the hierarchy and Cronbach's alpha coefficient for the internal consistency. Thirty-seven people participated in the reliability testing. Test-retest and inter-tester reliability were tested using the kappa coefficient. The testing was repeated on consecutive days to assess test-retest reliability and was scored simultaneously by two physiotherapists for inter-tester reliability. Fifty-five people participated in validity testing. The BBA was compared with the sitting Motor Assessment Scale (MAS), Berg Balance Test (Berg), Rivermead Mobility Index (RMI) using Spearman's rho. SETTING: Physiotherapy stroke services of six UK NHS trusts. PARTICIPANTS: Hemiplegic stroke patients were recruited from physiotherapy services and the BBA used to assess their balance. RESULTS: The order of the items was revised and the original 14-point scale reduced to 12 points in the scale development. The revised scale formed a hierarchical scale. Inter-item correlations were < 0.9, coefficients of reproducibility and scalability were 0.99 and 0.69 respectively and Cronbach's alpha was 0.92. Reliability was high (100% agreement) for both aspects of reliability. Correlations with other balance measures were significant (0.83-0.97, p < 0.01) indicating validity as measure of balance disability. CONCLUSION: The BBA is a reliable, valid, hierarchical measure of balance disability post stroke that is suitable for use in the clinical setting.