Pain catastrophizing predicts dropout of patients from an interdisciplinary chronic pain management programme: A prospective cohort study.

OBJECTIVE: To explore predictors of dropout of patients with chronic musculoskeletal pain from an interdisciplinary chronic pain management programme, and to develop and validate a multivariable prediction model, based on the Extended Common-Sense Model of Self-Regulation (E-CSM). METHODS: In this prospective cohort study consecutive patients with chronic pain were recruited and followed up (July 2013 to May 2015). Possible associations between predictors and dropout were explored by univariate logistic regression analyses. Subsequently, multiple logistic regression analyses were executed to determine the model that best predicted dropout. RESULTS: Of 188 patients who initiated treatment, 35 (19%) were classified as dropouts. The mean age of the dropout group was 47.9 years (standard devition 9.9). Based on the univariate logistic regression analyses 7 predictors of the 18 potential predictors for dropout were eligible for entry into the multiple logistic regression analyses. Finally, only pain catastrophizing was identified as a significant predictor. CONCLUSION: Patients with chronic pain who catastrophize were more prone to dropout from this -chronic pain management programme. However, due to the exploratory nature of this study no firm conclusions can be drawn about the predictive value of the E-CSM of Self-Regulation for dropout.

Dutch Translation and Adaptation of the Treatment Beliefs Questionnaire for Chronic Pain Rehabilitation.

Background: The Treatment Beliefs Questionnaire has been developed to measure patients' beliefs of necessity of and concerns about rehabilitation. Preliminary evidence suggests that these beliefs may be associated with attendance of rehabilitation. The aim of this study was to translate and adapt the Treatment Beliefs Questionnaire for interdisciplinary pain rehabilitation and to examine the measurement properties of the Dutch translation including the predictive validity for dropout. Methods: The questionnaire was translated in 4 steps: forward translation from English into Dutch, achieving consensus, back translation into English, and pretesting on providers and patients. In order to establish structural validity, internal consistency, construct validity, and predictive validity of the questionnaire, 188 participants referred to a rehabilitation centre for outpatient interdisciplinary pain rehabilitation completed the questionnaire at the baseline. Dropout was measured as the number of patients starting, but not completing the programme. For reproducibility, 51 participants were recruited at another rehabilitation centre to complete the questionnaire at the baseline and one week later. Results: We confirmed the structural validity of the Treatment beliefs Questionnaire in the Dutch translation with three subscales, necessity, concerns, and perceived barriers. internal consistency was acceptable with ordinal alphas ranging from 0.66-0.87. Reproducibility was acceptable with ICC2,1 agreement ranging from 0.67-0.81. Hypotheses testing confirmed construct validity, similar to the original questionnaire. Predictive validity showed the questionnaire was unable to predict dropouts. Conclusion: Cross-cultural translation was successfully completed, and the Dutch Treatment Beliefs Questionnaire demonstrates similar psychometric properties as the original English version.

[Home after a stroke; 'that's when it really begins'. A qualitative study into the needs for aftercare of stroke patients after being discharged home]. / Thuis na een CVA: 'Dan begint het pas'. Een kwalitatief onderzoek naar de behoefte aan nazorg van CVA-patiënten na terugkeer naar huis.

AIM: To explore stroke patients needs of care after discharge from hospital or rehabilitation facility. METHOD: Semi-structured interviews with twenty stroke patients and their partners in the region Midden-Kennemerland in the Netherlands. RESULTS: 'That's when it really begins'; at home it becomes clear what the real consequences of the stroke are on daily life. After returning home patients would have liked to (1) have had more information/support and they have a need for support for a long time after their stroke; (2) have had the possibility to get support later on (after having said 'no' in the first place). On the other hand there are (3) patients who are inclined to search for solutions by themselves. CONCLUSION: Only after returning home stroke patients and their partners can really assess what their need for care is. Therefore the need for care of stroke patients should be assessed after a period of time after the patients return home. The care should be available for a long time after the stroke. Because patients don't realize that they can get help for the neuropsychological consequences, it is important that the initiative to organize the care lies in the hands of the caregivers.

Differences in the relationship between psychosocial distress and self-reported disability in patients with chronic low back pain in six pain rehabilitation centers in the Netherlands.

STUDY DESIGN: A cross sectional multicenter study in six outpatient Rehabilitation Centers (RCs) in the Netherlands. OBJECTIVE: This study aims to confirm or refute the finding that a strong relationship exists between psychosocial distress and self-reported disability in patients with nonspecific chronic low back pain (CLBP) by analyzing this relationship in patients with CLBP admitted for treatment in six RCs. SUMMARY OF BACKGROUND DATA: A strong relationship between psychosocial distress and self-reported disability in patients with CLBP is suggested. However, in former research weak relationships were found in two of the RCs participating in this study. METHODS: Total study sample consisted of 293 patients (30-66 per RC) with CLBP, admitted for outpatient multidisciplinary rehabilitation in one of the six participating RCs. Psychosocial distress was measured with the Symptom Checklist-90-Revised (SCL-90-R), self-reported disability with the Roland Morris Disability Questionnaire (RMDQ). Pearson correlation coefficients between psychosocial distress and self-reported disability were calculated. Multivariate regression analysis was performed to analyze the relationship between SCL-90-R and VAS pain (independent variables) and RMDQ (dependent variable) for the total group and for each RC separately. A multivariate regression analysis was performed to analyze the relationship between all baseline characteristics and RMDQ in the total group. RESULTS: Correlation coefficient between the SCL-90-R and RMDQ was r = 0.38 for the total sample, indicating a significant (P < 0.05), but weak relationship. For the six individual RCs, correlation coefficients ranged between r = 0.22 and 0.67 (three of the six correlation coefficients were significant). The explained variance (r) of the regression models (SCL-90 and pain intensity as predictors of RMDQ) was 29% for the total sample, and varied between the RCs from 17% to 52%. Results of the multivariate regression analysis of all baseline characteristics of the total group revealed that the model explained 36% of the total variance observed in RMDQ score. Overall, the contributions of psychosocial distress to the models were smaller and more variable compared with pain intensity. CONCLUSION: The overall relationship between psychosocial distress and self reported disability was weak, and differences between RCs were considerable. This indicates that the relationship between psychosocial distress and disability in patients with CLBP is not uniform.

Adaptations to pain rehabilitation programmes for non-native patients with chronic pain.

PURPOSE: (i) To determine whether adaptations for non-native patients have been implemented in pain rehabilitation programmes; (ii) to determine whether characteristics of the rehabilitation institute are related to having adaptations for non-native patients in place. SUBJECTS: Rehabilitation institutes and rehabilitation departments of general hospitals in The Netherlands who offer a pain rehabilitation programme. METHOD: A questionnaire was handed over in person or by e-mail to the rehabilitation physicians of the participating institutes. Twenty-seven (90%) questionnaires were returned. The questionnaire concerned programme adaptations and institute characteristics. The data were analysed by χ(2) tests or Fischer's exact tests and logistic regression analysis. RESULTS: Twelve institutes (44.4%) reported having adaptations in place for non-native patients in their pain rehabilitation programme. The most common adaptations were as follows: increased number of consultations (25.9% of the institutes); longer consultations (25.9%) and education for employees regarding cultural competency (11.1%). Institutes which treated a high percentage (≥11%) of non-native patients had implemented significantly more frequently adaptations to their rehabilitation programme (p = 0.04). The number of adaptations was neither associated with the proportion of non-native citizens in the local population nor with the number of the institutes' employees. CONCLUSION: Less than half of the institutes had implemented one or more programme adaptations for non-native patients. Institutes which had made adaptations to their rehabilitation programme treated more non-native patients.

Reasons of drop-out from rehabilitation in patients of Turkish and Moroccan origin with chronic low back pain in The Netherlands: a qualitative study.

OBJECTIVE: To explore which factors led to drop-out in patients of Turkish and Moroccan origin with chronic non-specific low back pain who participated in a rehabilitation programme. SUBJECTS: Patients of Turkish or Moroccan origin with chronic non-specific low back pain (n = 23) from 2 rehabilitation centres and 4 rehabilitation departments of general hospitals in the Netherlands. METHODS: In-depth semi-structured interviews were conducted with patients of Turkish and Moroccan origin (n = 23), rehabilitation physicians (n = 8) and rehabilitation therapists (n = 2). Interviews were transcribed or summarized and subsequently coded and analysed according to themes. RESULTS: Most patients dropped out due to expectations of a specific medical diagnosis and pain relief as the main aims of rehabilitation treatment. Other reasons for drop-out detected in the interviews were: lack of acknowledgement of the patient's complaints, lack of trust in the rehabilitation physician, contradicting views to those of the physician from the patients' country of origin with regard to the cause and treatment of pain, and communication problems. CONCLUSION: The major reason for drop-out was patients having different expectations, from those of their health providers, of the aim of treatment, as a result of a different view of the origin and treatment of low back pain.

Higher dropout rate in non-native patients than in native patients in rehabilitation in The Netherlands.

Dropout from a rehabilitation programme often occurs in patients with chronic nonspecific low back pain of non-native origin. However, the exact dropout rate is not known. The objective of this study was to determine the difference in dropout rate between native and non-native patients with chronic nonspecific low back pain participating in a rehabilitation programme in The Netherlands. A retrospective study (n = 529) of patient files was performed in two rehabilitation centres and two rehabilitation departments of general hospitals in The Netherlands. Patient files were checked for diagnosis, status of origin, sex, age and outcome, that is, reason for finishing treatment. The difference in dropout rate between patients of Dutch and non-Dutch origin was tested by chi tests and logistic regression-analysis, controlling for age, sex, type of rehabilitation institute and phase of the rehabilitation programme. Dropout occurred among one fifth (18.7%) of the total patient population. Dropout among patients of non-Dutch origin was twice as high as among native Dutch patients (P < 0.001). In regression analyses dropout was related to status of non-Dutch origin, treatment in a rehabilitation centre and the diagnostic phase of a rehabilitation programme. In conclusion, patients of non-Dutch origin drop out considerably more frequently than native Dutch patients. Dropout is higher in the diagnostic phase than in the treatment phase and in rehabilitation centres than in hospitals. Future research should clarify the reasons for the high dropout rate in patients of non-native origin.

The benefits of theory for clinical practice: cognitive treatment for chronic low back pain patients as an illustrative example.

PURPOSE: To demonstrate, with the help of an example of cognitive treatment for patients with chronic low back pain, how a systematic description of the content and theoretical underpinnings of treatment can help to improve clinical practice. METHODS: A conceptual analysis, two types of theories, and a programme-theory framework were instrumental in systematically specifying the content of the treatment and the underlying assumptions. RESULTS: A detailed description of the cognitive treatment, including: (i) The intended outcomes; (ii) the related treatment components; (iii) the therapeutic process that is expected to mediate between outcomes and components, (iv) the conditions for optimal application; and (v) the guiding principles. CONCLUSIONS: The systematic description of the treatment revealed important issues for clinical practice, such as the patient and therapist characteristics that are needed for optimal provision of cognitive treatment. The discussions on the role of theory in rehabilitation practice are taken one step further in this clinical commentary: instead of simply describing the problems, we also demonstrated a means to tackle them.

Comorbidity, limitations in activities and pain in patients with osteoarthritis of the hip or knee.

BACKGROUND: This study aims to contribute to the knowledge of the influence of comorbidity in OA. The objectives of the study were (i) to describe the prevalence of comorbidity and (ii) to describe the relationship between comorbidity (morbidity count, severity and the presence of specific diseases) and limitations in activities and pain in elderly patients with knee or hip OA using a comprehensive inventory of comorbidity. METHODS: A cross-sectional cohort study was conducted, in which 288 elderly patients with hip or knee osteoarthritis were included. Apart from demographic and clinical data, information about comorbidity, limitations in activities (WOMAC, SF-36 and timed walking test) and pain (VAS) was collected by questionnaires and tests. Statistical analyses included descriptive statistics, multivariate regression techniques, t-tests and one-way ANOVA. RESULTS: Almost all patients suffered from at least one comorbid disease, with cardiac diseases, diseases of eye, ear, nose, throat and larynx, other urogenital diseases and endocrine/metabolic diseases being most prevalent. Morbidity count and severity index were associated with more limitations in activities and with more pain. The presence of most of the moderate or severe diseases and obesity was associated with limitations in activities or with pain. CONCLUSION: The results of this study emphasize the importance of comorbidity in the rehabilitation of elderly patients with osteoarthritis of the hip or knee. Clinical practitioners should be aware of the relationship of comorbidity with functional problems in OA patients.

Healing care? Rehabilitation of female immigrant patients with chronic pain from a family perspective.

PURPOSE: This pilot study aimed to address the social context of rehabilitation by exploring the perspectives of family members regarding rehabilitation of female immigrant patients with a chronic pain condition. METHOD: In-depth semi-structured, face-to-face interviews were conducted with family members of nine patients. The interviews were transcribed and subsequently coded and analysed according to themes. RESULTS: All participants acknowledged that their respective relative experiences pain. Pain is considered a symptom of the malfunctioning body and different explanatory notions are given. Participants regarded medication, warmth, rest or gentle exercise to be appropriate treatment options. Most participants had limited awareness of, and involvement in, rehabilitation. The role of family members in illness management lies mainly in providing advice and in taking over or assisting in domestic activities. CONCLUSION: The importance of considering the patient's social context and involving family in the treatment process is indicated in the literature. However, awareness of the aim and content of rehabilitation was limited among most participating family members as was their involvement in the rehabilitation process of their relative. It is recommended that further research needs to look at factors influencing involvement of family members before effective strategies for involving family members of patients of various socio-economic and/or cultural backgrounds can be developed.

Potential barriers to the use of health services among ethnic minorities: a review.

BACKGROUND: Ethnic minority patients seem to be confronted with barriers when using health services. Yet, care providers are often oblivious to these barriers, although they may share to some extent the burden of responsibility for them. In order to enlighten care providers, as to the potential pitfalls that may exist, there is a need to explore the different factors in the creation of the barriers. OBJECTIVE: Therefore, the objective of this paper is to present an overview of the potential barriers and the factors, which may restrict ethnic minority patients from using health services, according to the literature available. METHODS: Articles published from 1990 to 2003 were identified by searching electronic databases and selected through titles and abstracts. The articles were included if deemed to be relevant to study health services use by ethnic minorities, i.e. the different factors in the creation of a barrier. RESULTS: There were 54 articles reviewed. They reported on studies carried out in different countries and among different ethnic minorities. Potential barriers occurred at three different levels: patient level, provider level and system level. The barriers at patient level were related to the patient characteristics: demographic variables, social structure variables, health beliefs and attitudes, personal enabling resources, community enabling resources, perceived illness and personal health practices. The barriers at provider level were related to the provider characteristics: skills and attitudes. The barriers at system level were related to the system characteristics: the organisation of the health care system. CONCLUSION: This review has the goal of raising awareness about the myriad of potential barriers, so that the problem of barriers to health care for different ethnic minorities becomes transparent. In conclusion, there are many different potential barriers of which some are tied to ethnic minorities. The barriers are all tied to the particular situation of the individual patient and subject to constant adjustment. In other words, generalizations should not be made.

Reproducibility of plantar pressure measurements in patients with chronic arthritis: a comparison of one-step, two-step, and three-step protocols and an estimate of the number of measurements required.

BACKGROUND: Plantar pressure measurement may be a helpful evaluation tool in patients with foot complaints. Determination of dynamic pressure distribution under the foot may give information regarding gait, progress of disorders, and the effect of treatment. However, for these measurements to have clinical application, reproducibility, consistency, and accuracy must be ascertained. We compared the reproducibility of measurements among one-step, two-step, and three-step protocols for data collection in patients with arthritis. In addition, the number of measurements needed for a consistent average was determined for the protocol that was found to be the most reproducible. METHODS: Twenty patients with foot complaints secondary to arthritis participated in the study. Each patient was tested with a pressure platform system using two of the three testing protocols. Reproducibility of contact time and maximal peak pressure were assessed. Intraclass Correlation Coefficients (ICC) were calculated for measurement results among protocols. In stage two of the study, the number of measurements needed for a consistent average was determined by calculating the first three measurements, the first five measurements, and then all seven measurements for both feet. ICC of three, five, and seven measurements were compared. The two-step protocol (13 patients), which was found in stage one of the study to be the most reproducible, was used for this determination. RESULTS: Reproducibility was found to be reasonable or good for all three measurement protocols. The mean values of contact time for the one-step protocol were found to be higher than the mean values of contact time for the two-step or three-step protocols in both feet. The differences between the one-step and three-step protocols were statistically significant for the left foot only. The mean peak pressure did not show statistically-significant differences among the three protocols. The one-step and three-step protocols were not used for stage two of the study. Using the two-step protocol, three measurements were found to be sufficient for obtaining a consistent average. CONCLUSIONS: The results of our study indicated that the one-step, two-step, and three-step protocols of collecting plantar pressure measurements in patients with foot complaints secondary to chronic arthritis were all similar. However, the use of the two-step protocol is recommended over the one-step and three-step protocols; the one-step protocol produced a longer stance phase that did not resemble normal walking and when comparing the two-step and three-step protocols, the two-step protocol was less time consuming and less strenuous for patients with painful feet.

Correlates of resistance to HIV-1 infection in homosexual men with high-risk sexual behaviour.

OBJECTIVE: To investigate possible correlates of HIV resistance in participants from the Amsterdam Cohort of Homosexual men who have remained HIV seronegative despite high-risk sexual behaviour. DESIGN/METHODS: We studied in vitro HIV-1 susceptibility and adaptive and innate immunity in 29 high-risk seronegative (HRSN) and 15 HIV-negative pre-seroconversion (pre-SC) homosexual men from the same Amsterdam Cohort Study (ACS) who seroconverted to HIV-1 positive during active follow-up. Host genetics were compared between HRSN and HIV-positive ACS participants. RESULTS: We found lower in vitro susceptibility for a CCR5-using (R5) HIV-1 variant, higher RANTES production levels, but no difference in coreceptor expression in HRSN as compared with pre-SC controls. Reduced R5 in vitro susceptibility of two HRSN tested was restored to normal levels by addition of antibodies against beta-chemokines. A higher proportion of HRSN carried the SDF-1 3'A variant and HLA-A*11, A*31 and Cw*15 alleles. ELIspot analysis with HIV-1 peptide stimulation revealed low frequencies of HIV-1-specific CD8 interferon-gamma producing cytotoxic T cells in both HRSN and pre-SC controls. CONCLUSIONS: Low in vitro R5 susceptibility of cells from the HRSN men was due to beta-chemokine mediated inhibition of virus replication. The presence of HIV-1 specific cytotoxic T cells in both HRSN and pre-SC participants may signify exposure to the virus rather than protection from infection. Host genetic characteristics and other factors affecting innate immunity may contribute to differential resistance to HIV-1 infection among exposed seronegative individuals.

Decreasing sensitivity to RANTES (regulated on activation, normally T cell-expressed and -secreted) neutralization of CC chemokine receptor 5-using, non-syncytium-inducing virus variants in the course of human immunodeficiency virus type 1 infection.

In approximately half of human immunodeficiency virus (HIV) type 1-infected individuals, the development of CXC chemokine receptor 4-using, syncytium-inducing (SI) virus variants precedes a rapid progression to acquired immunodeficiency syndrome (AIDS). In other individuals, only CC chemokine receptor 5-using (R5), non-SI (NSI) virus variants are present throughout infection. These individuals may be either long-term survivors (LTSs) or rapid progressors. The basis for this variable disease progression in individuals with only R5 virus variants is not yet fully understood. In this study, the beta-chemokine sensitivity of biological HIV-1 clones isolated from 13 individuals who harbored only R5, NSI virus variants (7 LTSs and 6 progressors) was investigated. We found a statistically significant decrease in sensitivity of virus variants to RANTES (regulated on activation, normally T cell-expressed and -secreted) neutralization during the course of progressive infection, but not during follow-up of LTSs. Our data suggest that a role exists for RANTES neutralization sensitivity of HIV-1 in AIDS pathogenesis.

Treating patients with hemiplegic shoulder pain.

Studies on the efficacy of available methods of treatment for hemiplegic shoulder pain are reviewed in an attempt to identify the most effective treatment for this problem. Because of the poor quality of the 14 selected studies, no definite conclusion can be drawn about the most effective method of treatment. However, functional electrical stimulation and intra-articular triamcinolone acetonide injections seem to be the most promising treatment options.