Influence of ergonomic factors on peripheral neuropathy under HAV exposure.

BACKGROUND: Hand-arm vibration (HAV) is a risk factor for carpal tunnel syndrome (CTS) and ulnar neuropathy at the elbow (UNE). It is unclear how ergonomic factors influence the relationship between HAV exposure and CTS and UNE. AIMS: We aimed to assess the relationship between cumulative HAV exposure and CTS and UNE in workers exposed to HAV from two tools with different ergonomic profiles. METHODS: We performed nerve conduction studies (NCSs) of the sensory and motor median and ulnar nerves and recorded symptoms indicating CTS and UNE in workers exposed to HAV from impact wrenches or from rock drills. Exposure was measured as cumulative lifetime exposure. We used linear regression adjusted for age and body mass index to assess linear relationships. RESULTS: Sixty-five workers participated (33 rock drill and 32 impact wrench operators). We found inverse linear associations between cumulative HAV exposure and median nerve sensory conduction velocity in impact wrench operators and ulnar nerve motor conduction velocity in rock drill operators (beta of 0.63 and 0.75). Based on NCS findings and symptoms, seven impact wrench operators had CTS and one UNE, and four rock drill operators had CTS and six UNE. CONCLUSIONS: Our findings indicate that ergonomic factors influence the development of CTS and UNE under HAV exposure. The ergonomic profile seems to influence which type of neuropathy workers exposed to HAV will develop. Design of occupational exposure guidelines and future studies should be based on ergonomic profile and exposure characteristics for different tools and not merely HAV.

Complications, reoperations, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation.

AIMS: The aims of this study were to determine the rates of surgical complications, reoperations, and readmissions following herniated lumbar disc surgery, and to investigate the impact of sociodemographic factors and comorbidity on the rate of such unfavourable events. PATIENTS AND METHODS: This was a longitudinal observation study. Data from herniated lumbar disc operations were retrieved from a large medical database using a combination of procedure and diagnosis codes from all public hospitals in Norway from 1999 to 2013. The impact of age, gender, geographical affiliation, education, civil status, income, and comorbidity on unfavourable events were analyzed by logistic regression. RESULTS: Of 34 639 operations, 2.7% (95% confidence interval (CI) 2.6 to 2.9) had a surgical complication, 2.1% (95% CI 2.0 to 2.3) had repeat surgery within 90 days, 2.4% (95% CI 2.2 to 2.5) had a non-surgical readmission within 90 days, and 6.7% (95% CI 6.4 to 6.9) experienced at least one of these unfavourable events. Unfavourable events were found to be associated with advanced age and comorbidity. CONCLUSION: The results suggest that surgical complications are less frequent than previously suggested. There are limited associations between sociodemographic patient characteristics and unfavourable events. Cite this article: Bone Joint J 2019;101-B:470-477.

Measurement properties for the revised patient-reported OsteoArthritis Quality Indicator questionnaire.

OBJECTIVES: To assess validity, reliability, responsiveness and interpretability of the revised OsteoArthritis Quality Indicator (OA-QI) questionnaire version 2 (v2) assessing patient-reported quality of osteoarthritis care. METHODS: The OA-QI v2 (16 items, score range 0-100 (100 = best score)) was included in a longitudinal cohort study. Attendees of a 4.5 h osteoarthritis patient education programme at Diakonhjemmet Hospital, Norway, completed the OA-QI at four time points: 2 weeks before, immediately before, immediately after, and 3 months after the programme. Test-retest reliability and measurement error over a 2-week time period were assessed in those that had not seen health professionals in the interim. Construct validity and responsiveness were assessed with predefined hypotheses. Floor and ceiling effects, smallest detectable change (SDC95%) and minimal important change (MIC) were assessed to evaluate interpretability. RESULTS: The intraclass correlation coefficient for all 16 items was 0.89. For single items the test-retest kappa estimates ranged 0.38-0.85 and percent agreement 69-92%. Construct validity was acceptable with all six predefined hypotheses confirmed. Responsiveness was acceptable with 33 of 48 and three of four predefined hypotheses confirmed for single items and all items, respectively. There were no floor or ceiling effects. The SDC95% was 29.1 and 3.0 at the individual and group levels, respectively. MIC was 20.4. CONCLUSIONS: The OA-QI v2 had higher reliability estimates compared to v1, showed acceptable validity, and is the recommended version for future use. The results of responsiveness testing further support the use of the OA-QI v2 as an outcome measure in studies aiming to improve osteoarthritis care.

Pain-related fear and functional recovery in sciatica: results from a 2-year observational study.

OBJECTIVES: The purpose of this study was to explore the associations between pain-related fear, pain disability, and self-perceived recovery among patients with sciatica and disk herniation followed up for 2 years. PATIENTS AND METHODS: Pain-related fear was measured by the Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire-Physical Activity (FABQ-PA) subscale. Disability was measured by the Maine-Seattle Back Questionnaire. At 2 years, patients reported their sciatica/back problem on a global change scale ranging from completely gone to much worse. No specific interventions regarding pain-related fear were provided. RESULTS: Complete data were obtained for 372 patients. During follow-up, most patients improved. In those who at 2 years were fully recovered (n=66), pain-related fear decreased substantially. In those who did not improve (n=50), pain-related fear remained high. Baseline levels of pain-related fear did not differ significantly between those who were fully recovered and the rest of the cohort. In the total cohort, the correlation coefficients between the 0-2-year change in disability and the changes in the TSK and the FABQ-PA were 0.33 and 0.38, respectively. In the adjusted regression models, the 0-2-year change in pain-related disability explained 15% of the variance in the change in both questionnaires. CONCLUSION: Pain-related fear decreased substantially in patients who recovered from sciatica and remained high in those who did not improve. Generally, the TSK and the FABQ-PA yielded similar results. To our knowledge, this is the first study that has assessed pain-related fear in patients who recover from sciatica.

Evaluation of individualized quality of life and illness perceptions in low back pain. A patient education cluster randomized controlled trial.

OBJECTIVE: To evaluate the effect of a cognitive patient education intervention compared with usual care on secondary outcomes of individual quality of life and psychological outcomes of illness perceptions and pain catastrophizing in patients with low back pain. METHODS: A pragmatic cluster randomized controlled trial in which 16 general practitioners (GPs) and 20 physiotherapists (PTs) in primary care were randomly assigned to provide either a cognitive patient education intervention or usual treatment. Patients were followed up at 4 weeks and 12 months after treatment. Linear mixed models were used with group, time, type of clinician and interaction effects of group*time as fixed effects. RESULTS: A total of 203 patients provided data at baseline, 86% responded at 4 weeks and 74% at 12 months. For all the outcome measures there was a statistically significant effect of time (p<0.001) and type of clinician (p<0.05) during the follow-up year. There was a significant interaction effect of group×time on illness perceptions (p=0.003), however not for the other outcome measures. CONCLUSION: The cognitive patient education intervention initiated a faster improvement in illness perceptions but not in the other outcomes. PRACTICE IMPLICATIONS: A patient education intervention can be beneficial to improve illness perceptions, however more research is needed.

Limited effects of exercises in people with hand osteoarthritis: results from a randomized controlled trial.

OBJECTIVE: To determine the clinical effectiveness of an exercise programme on self-reported hand activity performance in people with hand osteoarthritis (OA). DESIGN: In this randomized, controlled trial, participants with physician-confirmed hand OA were randomly allocated to a 12-week exercise intervention (group- and home-based) or usual care. The primary outcome was self-reported hand activity performance at 3 months measured by the Functional Index for Hand Osteoarthritis (FIHOA) and a patient-generated measure of disability, the Patient-Specific Functional Scale (PSFS). RESULTS: Of 130 randomized participants (mean age 66 (standard deviation (SD) 9); female 90%), 120 (92%) and 119 (92%) completed the 3- and 6-month follow-ups. The adjusted mean difference for the exercise vs control group was -0.5 points (95% confidence interval (CI) -1.6, 0.6) for the FIHOA score (0-30 scale, 0 = best) and 0.9 points (95% CI 0.1, 1.7) for the PSFS score (0-10 scale, 10 = best). Small significant mean differences in favour of the intervention group were found for hand pain, hand stiffness and disease activity, whereas no mean differences were observed in hand dexterity or maximal grip strength. A significantly larger proportion in the intervention (46%) vs control group (16%) fulfilled the Outcome Measures in Rheumatological Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria at 3 months (OR = 4.4, 95% CI 1.9, 10.2). At the 6-month follow-up, there were no significant group differences in any outcome. CONCLUSIONS: The exercise programme was well tolerated among people with hand OA, but resulted only in small, beneficial short-term improvements on self-reported measures and not on most performance-based tests. Future studies should address optimal grip strength exercises and dosage. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT01245842.

The prognosis of self-reported paresthesia and weakness in disc-related sciatica.

PURPOSE: To explore how patients with sciatica rate the 'bothersomeness' of paresthesia (tingling and numbness) and weakness as compared with leg pain during 2 years of follow-up. METHODS: Observational cohort study including 380 patients with sciatica and lumbar disc herniation referred to secondary care. Using the Sciatica Bothersomeness Index paresthesia, weakness and leg pain were rated on a scale from 0 to 6. A symptom score of 4-6 was defined as bothersome. RESULTS: Along with leg pain, the bothersomeness of paresthesia and weakness both improved during follow-up. Those who received surgery (n = 121) reported larger improvements in both symptoms than did those who were treated without surgery. At 2 years, 18.2% of the patients reported bothersome paresthesia, 16.6% reported bothersome leg pain, and 11.5% reported bothersome weakness. Among patients with no or little leg pain, 6.7% reported bothersome paresthesia and 5.1% bothersome weakness. CONCLUSION: During 2 years of follow-up, patients considered paresthesia more bothersome than weakness. At 2 years, the percentage of patients who reported bothersome paresthesia was similar to the percentage who reported bothersome leg pain. Based on patients' self-report, paresthesia and weakness are relevant aspects of disc-related sciatica.

The predictive validity of the Örebro Musculoskeletal Pain Questionnaire and the clinicians' prognostic assessment following manual therapy treatment of patients with LBP and neck pain.

The purpose of this study was to compare the predictive ability of the standardised screening tool Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) and the clinicians' prognostic assessment in identifying patients with low back pain (LBP) and neck pain at risk for persistent pain and disability at eight weeks follow-up. Patients seeking care for LBP or neck pain were recruited by 19 manual therapists in Norway. Patients completed the ÖMPQ and the low back- or neck specific Oswestry Disability Index/Neck Disability Index at baseline and 8 weeks after first consultation. The manual therapists filled in their assessment of patient's prognosis immediately after the first consultation, blinded for patient's answers to the questionnaire. A total of 157 patients (81with neck pain and 76 with LBP) were included. The best odds for predicting the outcome for LBP patients was found for the clinicians' assessment of prognosis (LR+ = 2.1 and LR- = 0.55), whereas the likelihood ratios were similar for the two tools in the neck group. For LBP patients, both the clinicians' assessment and the ÖMPQ contributed significantly in the separate regression models (p = 0.02 and p = 0.002, resp), whereas none of the tools where significant contributors for neck patients (p = 0.67 and 0.07). Neither of the two methods showed high precision in their predictions of follow-up at eight weeks. However, for LBP patients, the ÖMPQ and the clinicians' prognostic assessment contributed significantly in the prediction of functional outcome 8 weeks after the initial assessment of manual therapist, whereas the prediction for neck patients was unsure.

Does the content really matter? A study comparing structure, process, and outcome of team rehabilitation for patients with inflammatory arthritis in two different clinical settings.

OBJECTIVES: To provide a thorough description of team rehabilitation care and compare the structure, process, and outcomes in two specialized arthritis rehabilitation settings. METHODS: Patients with inflammatory arthritis scheduled for inpatient rehabilitation in seven specialized rehabilitation centres and three rheumatology hospital departments in Norway were included consecutively in a prospective cohort study. Patients completed questionnaires at admission, at discharge, and at a 6-month follow-up, and kept a diary regarding structure and process variables during the rehabilitation stay. RESULTS: Eighty patients in rehabilitation centres and 73 in hospital departments were included and 80% responded to the 6-month follow-up questionnaire. The two clinical settings differed significantly with regard to structure variables such as cost, referral of patients, length of stay, and number of health professionals involved, and most process variables reflecting treatment modalities. The most remarkable difference was in the amount of individual intervention compared with group intervention. Despite significant improvements in most outcomes at discharge, the scores deteriorated towards baseline level 6 months later. There was a trend towards more significant improvement during rehabilitation for patients at rehabilitation centres whereas patients at hospitals had more prolonged improvement. CONCLUSIONS: Team rehabilitation for inflammatory arthritis in two different clinical settings differed across most variables for structure and process, but few significant differences in outcome were found. Considering the substantial differences in cost, there is an urgent need for consensus concerning which patients should receive rehabilitation in which setting. Future research on the development and evaluation of methods for prolonging the beneficial effects of rehabilitation is needed.

Patient experiences of rehabilitation in rheumatology: association with process and outcome.

OBJECTIVE: To evaluate health-care experiences of patients following inpatient rheumatology rehabilitation and to assess the association between these experiences and aspects of health-care delivery and patient characteristics. METHODS: Data were collected from 435 patients with a rehabilitation stay of >or= 1 week at 12 institutions in Norway in 2006. At discharge, patients completed the Rehabilitation Patient Experiences Questionnaire (Re-PEQ), which includes four important aspects of patient experiences. Multiple regression analysis was used to assess associations between Re-PEQ scores, health-care process, health and sociodemographic variables. RESULTS: A total of 412 (94.7%) patients completed the Re-PEQ; scores ranged from 69 (social environment) to 83 (care/organization) on the 0-100 scale, where 100 represents the best possible experience. The social environment scale had the largest component of variation explained by the independent variables, which included number of doctor visits, amount of group education, and individual exercise (p < 0.01). The type of institution, number of doctor visits, mental health, and gender also explained significant components of variation in the other Re-PEQ scale scores. CONCLUSION: Patients reported good experiences with rheumatology rehabilitation. Areas where poorer experiences emerged can help target areas for future initiatives aimed at improving the quality of care. Health and sociodemographic variables should be controlled for in studies of patient experiences.

Systematic review of back schools, brief education, and fear-avoidance training for chronic low back pain.

BACKGROUND: Seven previous systematic reviews (SRs) have evaluated back schools, and one has evaluated brief education, with the latest SR including studies until November 2004. The effectiveness of fear-avoidance training has not been assessed. PURPOSE: To assess the effectiveness of back schools, brief education, and fear-avoidance training for chronic low back pain (CLBP). STUDY DESIGN: A SR. METHODS: We searched the MEDLINE database of randomized controlled trials (RCT) until August 2006 for relevant trials reported in English. Assessment of effectiveness was based on pain, disability, and sick leave. RCTs that reported back schools, or brief education as the main intervention, were included. For fear-avoidance training, evaluation of domain-specific outcome was required. Two reviewers independently reviewed the studies. RESULTS: Eight RCTs including 1,002 patients evaluated back schools, three studies were of high quality. We found conflicting evidence for back schools compared with waiting list, placebo, usual care, and exercises, and a cognitive behavioral back school. Twelve trials including 3,583 patients evaluated brief education. Seven trials, six of high quality, evaluated brief education in the clinical setting. We found strong evidence of effectiveness on sick leave and short-term disability compared with usual care. We found conflicting or limited evidence for back book or Internet discussion (five trials, two of high quality) compared with waiting list, no intervention, massage, yoga, or exercises. Three RCTs of high quality, including 364 patients, evaluated fear-avoidance training. We found moderate evidence that there is no difference between rehabilitation including fear-avoidance training and spinal fusion. CONCLUSIONS: Consistent recommendations are given for brief education in the clinical setting, and fear-avoidance training should be considered as an alternative to spinal fusion, and back schools may be considered in the occupational setting. The discordance between reviews can be attributed differences in inclusion criteria and application of evidence rules.

Cross-cultural adaptation of the Norwegian versions of the Roland-Morris Disability Questionnaire and the Oswestry Disability Index.

OBJECTIVE: To evaluate reliability and construct validity of the Norwegian versions of the Roland Morris Disability Questionnaire and the modified Oswestry Disability Index. DESIGN: Translation of two functional status questionnaires and a cross-sectional study of measurement properties. METHODS: The questionnaires were translated and back-translated following the Guillemin criteria. The Norwegian versions were tested for 55 patients with acute low back pain and 50 patients with chronic low back pain. Test-retest with a 2-day interval was performed in a subsample of 28 patients from the chronic sample. Reliability was assessed by repeatability according to Bland and Altman, intraclass coefficient and coefficient of variation. Internal consistency was assessed by Cronbach's alpha. Concurrent construct validity was assessed with correlations between the questionnaires and the SF-36, Disability Rating Index and pain intensity. RESULTS: Repeatability of the Roland Morris Disability Questionnaire was 4 points, coefficient of variation 15% and intraclass correlation coefficient 0.89, and of the modified Oswestry Disability Index 11, 12% and 0.88, respectively. Internal consistency was 0.94 for both questionnaires. The questionnaires correlated highly with the physical functioning scale of SF-36, moderately with pain, and low with mental scales of the SF-36. CONCLUSION: The reliability and construct validity of the Norwegian versions of the Roland Morris Disability Questionnaire and the modified Oswestry Disability Index are acceptable for assessing functional status of Norwegian-speaking patients with low back pain.