Exploring the feasibility of a network of organizations for pain rehabilitation: What are the lessons learned?

BACKGROUND AND AIMS: Integration of care is lacking for chronic musculoskeletal pain patients. Network Pain Rehabilitation Limburg, a transmural health care network, has been designed to provide integrated rehabilitation care from a biopsychosocial perspective to improve patients' levels of functioning. This feasibility study aims to provide insight into barriers and facilitators for the development, implementation, and transferability. METHODS: This study was conducted with a three-phase iterative and incremental design from October 2017 to October 2018. The network comprises two rehabilitation practices, and three local primary care networks, with a general practitioner together with, a mental health practice nurse, and a physiotherapist or exercise therapist. These stakeholders with a random sample of participating patients took part in evaluations, consisting of interviews, focus groups, and observations. Field notes and observations were recorded during meetings. The Consolidated Framework for Implementation Research guided data collection and analysis. Results were used to refine the next phase. RESULTS: According to health care professionals, guidelines and treatment protocols facilitate consistency and transparency in collaboration, biopsychosocial language, and treatment. One mentioned barrier is the stigmatization of chronic pain by the general population. In regular care, approaches are often more biomedical than biopsychosocial, causing patients to resist participating. The current organization of health care acts as a barrier, complicating implementation between and within practices. Health care professionals were enthusiastic about the iterative, bottom-up development. A critical mass of participating organizations is needed for proper implementation. CONCLUSION: Network Pain Rehabilitation Limburg is feasible in daily practice if barriers are overcome and facilitators of development, implementation, and transferability are promoted. These findings will be used to refine Network Pain Rehabilitation Limburg. A large-scale process and effect evaluation will be performed. Our implementation strategies and results may assist other health care organizations aspiring to implement a transmural network using a similar model. TRAIL REGISTRATION: Registration number: NTR6654 or https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6654.

An eCoach-Pain for Patients with Chronic Musculoskeletal Pain in Interdisciplinary Primary Care: A Feasibility Study.

eHealth could support cost-effective interdisciplinary primary care for patients with chronic musculoskeletal pain. This study aims to explore the feasibility of the eCoach-Pain, comprising a tool measuring pain complexity, diaries, pain education sessions, monitoring options, and chat function. Feasibility was evaluated (June-December 2020) by assessing learnability, usability, desirability, adherence to the application, and experiences from patients and general practitioners, practice nurses mental health, and physiotherapists. Six primary healthcare professionals (PHCPs) from two settings participated in the study and recruited 29 patients (72% female, median age 50.0 years (IQR = 24.0)). PHCPs participated in a focus group. Patient data was collected by evaluation questionnaires, individual interviews, and eCoach-Pain-use registration. Patients used the eCoach during the entire treatment phase (on average 107.0 days (IQR = 46.0); 23 patients completed the pain complexity tool and used the educational sessions, and 12 patients the chat function. Patients were satisfied with the eCoach-Pain (median grade 7.0 (IQR = 2.8) on a 0-10 scale) and made some recommendations for better fit with patient-specific complaints. According to PHCPs, the eCoach-Pain is of added value to their treatment, and patients also see treatment benefits. However, the implementation strategy is important for successful use of the eCoach-Pain. It is recommended to improve this strategy and involve a case-manager per patient.

Interdisciplinary Care Networks in Rehabilitation Care for Patients with Chronic Musculoskeletal Pain: A Systematic Review.

This systematic review aims to identify what rehabilitation care networks, within primary care or between primary and other health care settings, have been described for patients with chronic musculoskeletal pain, and what their impact is on the Quadruple Aim outcomes (health; health care costs; quality of care experienced by patients; work satisfaction for health care professionals). Studies published between 1 January 1994 and 11 April 2019 were identified in PubMed, CINAHL, Web of Science, and PsycInfo. Forty-nine articles represented 34 interventions: 21 within primary care; 6 between primary and secondary/tertiary care; 1 in primary care and between primary and secondary/tertiary care; 2 between primary and social care; 2 between primary, secondary/tertiary, and social care; and 2 between primary and community care. Results on impact were presented in 19 randomized trials, 12 non-randomized studies, and seven qualitative studies. In conclusion, there is a wide variety of content, collaboration, and evaluation methods of interventions. It seems that patient-centered interdisciplinary interventions are more effective than usual care. Further initiatives should be performed for interdisciplinary interventions within and across health care settings and evaluated with mixed methods on all Quadruple Aim outcomes.

An exploratory study of discrepancies between objective and subjective measurement of the physical activity level in female patients with chronic fatigue syndrome.

OBJECTIVE: To explore the ability of a self-report activity diary to measure the physical activity level (PAL) in female patients with chronic fatigue syndrome (CFS) and whether illness-related complaints, health-related quality of life domains (HRQOL) or demographic factors are associated with discrepancies between self-reported and objectively measured PAL. METHODS: Sixty-six patients with CFS, recruited from the chronic fatigue clinic of a university hospital, and twenty matched healthy controls wore an accelerometer (Actical) for six consecutive days and registered their activities in an activity diary in the same period. Participants' demographic data was collected and all subjects completed the CFS Symptom List (illness-related complaints) daily and Short-Form-36 (HRQOL domains) during the first and second appointment. RESULTS: A significant, but weak association between the activity diary and Actical was present in patients with CFS (rs = 0.376 and rs = 0.352; p < 0.001) and a moderately strong association in healthy controls (rs = 0.605; and rs = 0.644; p < 0.001) between week and weekend days, respectively. A linear mixed model identified a negative association between age and the discrepancy between the self-reported and objective measure of PA in both patients with CFS and healthy controls. CONCLUSION: The activity diary showed limited ability to register the PAL in female patients with CFS. The discrepancy between measures was not explained by illness-related complaints, HRQOL domains or demographic factors. The activity diary cannot replace objective activity monitoring measured with an accelerometer, but may provide additional information about the perceived activity.

Are chronic musculoskeletal pain and generalized joint hypermobility disabling contributors to physical functioning?

BACKGROUND: Chronic musculoskeletal pain (CMP), Generalized Joint Hypermobility (GJH) and pain-related fear have influence on physical functioning in adolescents. AIM: to evaluate differences in physical functioning between adolescents with CMP, GJH or the combination of both, and in addition evaluate the potential contribution of pain-related fear. DESIGN: The design of this study was observational and cross-sectional. SETTING: The adolescents with CMP were recruited by a physician in rehabilitation medicine and measured in the university outpatient rehabilitation clinic (Adelante/Maastricht University Medical Center+, the Netherlands). The adolescents without CMP were recruited in the Southern area of the Netherlands and measured in the university outpatient rehabilitation clinic (Adelante/Maastricht University Medical Center+, the Netherlands). POPULATION: Four subgroups of adolescents were included; 21 adolescents with CMP without GJH, 9 adolescents with CMP and GJH, 51 adolescents without CMP without GJH, and 11 adolescents without CMP with GJH. METHODS: Outcome measures were muscle strength and endurance, motor performance, physical activity level, and pain-related fear. Hierarchical regression analyses were used to study differences in physical functioning and the contribution of pain-related fear in adolescents with/without CMP as well as with/without GJH. RESULTS: Adolescents with CMP had decreased muscle strength (P=0.01), endurance (P=0.02), and lower motor performance (P<0.01) compared to adolescents without CMP. Higher levels of pain-related fear were related to decreased muscle strength (P=0.01), endurance (P<0.01), and motor performance (P<0.01). No differences in physical functioning and pain-related fear between hypermobile and non-hypermobile adolescents with CMP were found. CONCLUSIONS: Adolescents with CMP had decreased muscle strength and motor performance associated with increased levels of pain-related fear compared to adolescents without CMP. The association of being hypermobile with physical functioning is not more pronounced in adolescents with CMP. CLINICAL REHABILITATION IMPACT: No differences were found in physical functioning and pain-related fear between hypermobile adolescents with CMP compared to non-hypermobile adolescents with CMP. Future rehabilitation treatment in hypermobile adolescents with CMP should also focus on psychological components, such as pain-related fear.

Generalized joint hypermobility and perceived harmfulness in healthy adolescents; impact on muscle strength, motor performance and physical activity level.

Objective: The first aim of this study was to determine whether adolescents with asymptomatic Generalized Joint Hypermobility (GJH) have a lower level of physical functioning (physical activity level, muscle strength and performance) compared to non-hypermobile controls. Secondly, to evaluate whether the negative impact of perceived harmfulness on physical functioning was more pronounced in adolescents with asymptomatic GJH.Methods: Cross-sectional study. Sixty-two healthy adolescents (mean age 16.8, range 12-21) participated. Hypermobility (Beighton score), perceived harmfulness (PHODA-youth) and muscle strength (dynamometry), motor performance (Single-Leg-Hop-for-Distance) and physical activity level (PAL) (accelerometry) were measured. Hierarchical regression analyses were used to study differences in physical functioning and perceived harmfulness between asymptomatic GJH and non-hypermobile controls.Results: Asymptomatic GJH was associated with increased knee extensor muscle strength (peak torque/body weight; PT/BW), controlled for age and gender (dominant leg; ß = 0.29; p = .02). No other associations between asymptomatic GJH and muscle strength, motor performance and PAL were found. Perceived harmfulness was not more pronounced in adolescents with asymptomatic GJH.Conclusions: Adolescents with asymptomatic GJH had increased knee extensor muscle strength compared to non-hypermobile controls. No other differences in the level of physical functioning was found and the negative impact of perceived harmfulness was not more pronounced in adolescents with asymptomatic GJH.

Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain.

OBJECTIVES: A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability. CONTENT: Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability. SUMMARY AND OUTLOOK: It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism.In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.

The (cost-)effectiveness and cost-utility of a novel integrative care initiative for patients with chronic musculoskeletal pain: the pragmatic trial protocol of Network Pain Rehabilitation Limburg.

BACKGROUND: Rehabilitation care for patients with chronic musculoskeletal pain (CMP) is not optimally organized. The Network Pain Rehabilitation Limburg 2.0 (NPRL2.0) provides integrated care with a biopsychosocial approach and strives to improve the Quadruple Aim outcomes: pain-related disability of patients with CMP; experiences of care of patients with CMP; meaning in the work of healthcare professionals; and healthcare costs. Firstly, in this study, the effectiveness (with regard to the functioning and participation of patients) of primary care for patients with CMP will be assessed, comparing care organized following the NPRL2.0 procedure with usual care. Secondly, the cost-effectiveness and cost-utility with regard to health-related quality of life and healthcare costs will be assessed. And thirdly, the effect of duration of participation in a local network in primary care will be studied. METHODS: In this pragmatic study, it is expected that two local networks with 105 patients will participate in the prospective cohort study and six local networks with 184 patients in the stepped-wedge based design. Healthcare professionals in the local networks will recruit patients. INCLUSION CRITERIA: age ≥ 18 years; having CMP; willing to improve functioning despite pain; and adequate Dutch literacy. EXCLUSION CRITERIA: pregnancy; and having a treatable medical or psychiatric disease. Patients will complete questionnaires at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4). Questionnaires at T1 and T4 will include the Pain Disability Index and Short Form Health Survey. Questionnaires at T1, T2, T3, and T4 will include the EQ-5D-5L, and iMTA Medical Consumption and Productivity Cost Questionnaires. Outcomes will be compared using linear mixed-model analysis and costs will be compared using bootstrapping methods. DISCUSSION: NPRL2.0 is a multidimensional, complex intervention, executed in daily practice, and therefore needing a pragmatic study design. The current study will assess NPRL2.0 with respect to the Quadruple Aim outcomes: patient health and costs. This will provide more information on the (cost-) effectiveness of the organization of care in a network structure regarding patients with CMP. The other two Quadruple Aim outcomes will be examined alongside this study. Trial registration Netherlands Trial Register: NL7643. https://www.trialregister.nl/trial/7643 .

Multidisciplinary Treatment for Hypermobile Adolescents with Chronic Musculoskeletal Pain.

BACKGROUND: To determine whether adolescents with generalized hypermobility spectrum disorder/ hypermobile Ehlers-Danlos syndrome (G-HSD/ hEDS) show changes in the level of disability, physical functioning, perceived harmfulness and pain intensity after completing multidisciplinary rehabilitation treatment. METHODS: Pre-test post-test design. Fourteen adolescents with G-HSD/hEDS participated. The multidisciplinary rehabilitation treatment consisted of a combination of physical training and exposure in vivo. Physical training aims to improve aerobic capacity, muscle strength and propriocepsis for compensating hypermobility. Exposure in vivo aims to decrease disability and pain-related fear. Pre- and post-treatment assessments were conducted to assess the level of disability, physical functioning (motor performance, muscle strength and physical activity level), perceived harmfulness and pain intensity. RESULTS: After completing multidisciplinary rehabilitation treatment, the adolescents showed a significant and clinically relevant improvement (improvement of 67%, p<0.01) in functional disability. Furthermore, significant improvements were found in motor performance (p < 0.01), muscle strength (p < 0.05), perceived harmfulness (p < 0.01) and pain intensity (p <0.01) after completing multidisciplinary rehabilitation treatment. CONCLUSION: Multidisciplinary rehabilitation treatment leads to a significantly and clinically relevant improvement in the level of disability for adolescents with G-HSD/hEDS. Positive effects were also found in physical functioning, perceived harmfulness and pain intensity. Although the results of this multidisciplinary rehabilitation treatment for adolescents with G-HSD/hEDS are promising, further study is needed to confirm these findings in a randomized design.

Subgrouping patients with chronic low back pain: What are the differences in actual daily life behavior between patients classified as avoider or persister?

BACKGROUND AND OBJECTIVE: The purpose of this study is to determine whether patients, classified by their treating consultant in rehabilitation medicine as avoider or persister, show differences in a large set of detailed outcomes of actual, objectively measured daily physical behaviour. METHODS: In this explorative cross-sectional study, 16 patients were included; 9 patients were categorized as avoider and 7 patients as persister. Subjects wore the VitaMove activity monitor, a high-end accelerometry-based device that allowed automatic detection of a large set of body postures and motions. Physical behaviour was assessed in detail by total duration of body postures and motions as percentages of 24 hours, as well as by the number of sit-to-stand transfers, overall activity level, walking speed, and the distribution of bouts of physical activity and sedentary behaviour. Differences between groups were tested with the Mann Whitney U test. RESULTS: There were no significant differences between groups in any of the physical behaviour outcomes. CONCLUSIONS: Our study showed that activity-related behavioural style categorization by consultants in rehabilitation medicine is not expressed in objectively measured detailed outcomes of daily physical behaviour.

Developing the Network Pain Rehabilitation Limburg: a feasibility study protocol.

INTRODUCTION: Patients having chronic musculoskeletal pain (CMP) face challenges as mismatches often exist between the complexity of patient's pain problem and the rehabilitation treatment offered. This can result in less efficient care for the patient and increased medical shopping. The Network Pain Rehabilitation Limburg (NPRL), a transmural integrated healthcare network, will be designed to improve daily care for patients with CMP. NPRL focusses on improving patient's level of functioning despite pain by stimulating a biopsychosocial approach given by all involved healthcare professionals. A feasibility study will be performed which will give insight into the barriers and facilitators, perceived value, acceptability and implementation strategies for NPRL. METHODS AND ANALYSIS: This study has a three-phase iterative and incremental design, based on key principles of a user-centred design. Mixed methods will be used in which healthcare professionals and patients involved in NPRL will participate. In phase 1, NPRL will be developed and healthcare professionals educated. Phase 2 focusses on the implementation and phase 3 on the transferability of NPRL. In addition, preliminary data on patient's work status, general health and participation level will be collected. The qualitative results of each phase will be analysed following the Consolidated Framework for Implementation Research (CFIR) and will be used to refine NPRL in daily practise. ETHICS AND DISSEMINATION: Informed consent will be obtained from all participants. The results of this feasibility study will form the basis for refinement of NPRL and planning of a large-scale process and effect evaluation of the Quadruple Aim outcomes. Dissemination will include publications and presentations at national and international conferences. Ethical approval for this study was granted by the Medical Ethics Committee Z, the Netherlands, METC 17 N-133.

Effectiveness of Primary Care Interventions Using a Biopsychosocial Approach in Chronic Low Back Pain: A Systematic Review.

BACKGROUND AND OBJECTIVE: Recent systematic reviews show promising effects for multidisciplinary biopsychosocial (BPS) interventions in patients with chronic low back pain (CLBP). Nowadays, BPS interventions have also been developed for primary care physiotherapy settings. Our aim was to systematically review the evidence on the effectiveness of primary care BPS interventions in improving functional disability, pain, and work status for patients with CLBP. Secondly, we aimed to provide an elaborated overview of BPS intervention designs, physiotherapist training programs, and process-related factors (practical implementation). METHODS: We searched in scientific databases and reference lists. Randomized controlled trials (RCTs) evaluating primary care physiotherapist-led BPS interventions in adults (≥18 years) with nonspecific CLBP (≥12 weeks) were included. RESULTS: Our search resulted in 943 references; 7 RCTs were included (1,426 participants). Results show moderate-quality evidence (3 trials; 991 participants) that a BPS intervention is more effective than education/advice for reducing disability and pain in the short, medium, and long term. Low-quality evidence (4 trials; 435 participants) was found for no difference with physical activity treatments. CONCLUSIONS: BPS interventions seem more effective than education/advice and were found to be as effective as physical activity interventions in patients with CLBP. BPS interventions with a clear focus on psychosocial factors (understanding pain, unhelpful thoughts, coping styles, and goal setting) seem most promising. Sufficient delivery of BPS elements is expected when physiotherapists participate in training programs with extensive support prior and during delivery (manual, supervision, and informative resources).

Psychometric Properties of the Photograph Series of Daily Activities-Short Electronic Version (PHODA-SeV) in Patients With Chronic Low Back Pain.

Background The Photograph Series of Daily Activities-short electronic version (PHODA-SeV) assesses perceived harmfulness of daily activities in patients with low back pain (LBP). Although there is some evidence that the PHODA-SeV is a reliable and valid tool, its psychometric properties have not been fully investigated. Objectives To investigate the test-retest reliability, measurement error, interpretability, construct validity, and internal and external responsiveness of the PHODA-SeV in patients with chronic LBP. Methods Ninety-one patients were included in the analysis for this prospective cohort study. For reliability purposes, the PHODA-SeV was administered twice, with a 1-week interval before beginning treatment. Pain, disability, and measures of pain-related fear (ie, PHODA-SeV, Fear-Avoidance Beliefs Questionnaire [FABQ], and Tampa Scale of Kinesiophobia [TSK]) were collected before and after the 8-week treatment period. Results The PHODA-SeV showed excellent reliability (intraclass correlation coefficient model 2,1 = 0.91), without evidence of ceiling and floor effects. The construct validity analysis demonstrated fair correlations (r = 0.25-0.50) of the PHODA-SeV with the FABQ, but no correlation with the TSK (r<0.25). For internal responsiveness, the PHODA-SeV showed an effect size of 0.87 and a standardized response mean of 0.92, interpreted as a large effect (greater than 0.80). For external responsiveness, the correlations between the PHODA-SeV and changes in the TSK and FABQ were considered low, and the receiver operating characteristic curve analyses revealed an area under the curve lower than the proposed threshold of 0.70. Conclusion The PHODA-SeV is a reliable tool that can detect changes over time in pain-related fear in patients with chronic LBP undergoing physical therapy treatment. This tool, however, failed to identify those patients who did or did not improve, according to other pain-related fear measures. J Orthop Sports Phys Ther 2018;48(9):719-727. Epub 23 May 2018. doi:10.2519/jospt.2018.7864.

Spinal Surgeons' Opinions on Pre- and Postoperative Rehabilitation in Patients Undergoing Lumbar Spinal Fusion Surgery: A Survey-Based Study in the Netherlands and Sweden.

STUDY DESIGN: A cross-sectional survey in the Netherlands and Sweden. OBJECTIVE: To investigate Dutch and Swedish spinal surgeons' opinions on spinal fusion pre- and postoperative rehabilitation. SUMMARY OF BACKGROUND DATA: Lumbar spinal fusion surgery is increasingly provided in patients with chronic low back pain. No guidelines however exist for pre- and postoperative rehabilitation and it is unknown what opinions spinal surgeons currently have about pre- and postoperative rehabilitation. METHODS: A survey was circulated to Dutch and Swedish spinal surgeons. Reminders were sent after 4 and 8/9 weeks. Data of completed questionnaires of orthopedic- and neurosurgeons currently performing lumbar spinal fusion were included for analysis. Analysis comprised a range of descriptive summaries (numerical, graphical, and tabular). RESULTS: Surveys of 34 Dutch and 48 Swedish surgeons were analyzed. Surgeons provided preoperative information on postoperative mobilization. Spinal fusion techniques varied, but technique did not influence postoperative treatment. Swedish surgeons recommended slightly faster mobilization than Dutch (direct vs. 1-day postoperative), and more activities the first day (sitting, standing, walking). Stair climbing was the most reported discharge criterion; however, time point to start varied. More Swedish surgeons referred to postoperative physiotherapy than Dutch (88% vs. 44%). Time-point to start home activities varied from 1 week to more than 6 months. Pain increase was allowed for less than 24 hours (The Netherlands 81%, Sweden 92%). CONCLUSION: Findings reflect variability in lumbar spinal fusion rehabilitation in two European countries, especially in postoperative phase. The study proposes many new research topics and acts as starting point for future research valuable for the spinal community. LEVEL OF EVIDENCE: 3.

Pain-Related Fear and Its Disabling Impact in Hypermobile Adolescents With Chronic Musculoskeletal Pain.

Study Design Cross-sectional study. Background Chronic musculoskeletal pain (CMP) has a negative impact on physical functioning. During adolescence, joint hypermobility is a potential risk factor for developing CMP, and pain-related fear contributes to the persistence of CMP. Whether pain-related fear and hypermobility are related, and even reinforce each other, resulting in a stronger association with perceived level of disability, is still unknown. Objectives To evaluate whether pain-related fear has a stronger association with disability in hypermobile compared to nonhypermobile adolescents with CMP. Methods The study included 116 adolescents with CMP. The presence of hypermobility was assessed using the Beighton score. Measures of pain intensity, age, sex, and pain-related fear were collected and included in the multivariable model. Hierarchical regression analysis, with disability as the dependent variable, was used to examine the interaction between hypermobility and pain-related fear. Results Hypermobile adolescents with CMP do not have more pain-related fear compared to nonhypermobile adolescents with CMP. There was no interaction effect between hypermobility and pain-related fear in explaining disability (ß = .20, P = .42). Similarly, perceived harmfulness of balance-related activities was not more strongly associated with disability in hypermobile adolescents with CMP. Conclusion The association of pain-related fear with the perceived level of disability is not more pronounced in hypermobile compared to nonhypermobile adolescents with CMP. J Orthop Sports Phys Ther 2017;47(10):775-781. Epub 12 Sep 2017. doi:10.2519/jospt.2017.7282.

Economic evaluation of multidisciplinary rehabilitation treatment versus cognitive behavioural therapy for patients with chronic fatigue syndrome: A randomized controlled trial.

BACKGROUND: A multi-centre RCT has shown that multidisciplinary rehabilitation treatment (MRT) is more effective in reducing fatigue over the long-term in comparison with cognitive behavioural therapy (CBT) for patients with chronic fatigue syndrome (CFS), but evidence on its cost-effectiveness is lacking. AIM: To compare the cost-effectiveness of MRT versus CBT for patients with CFS from a societal perspective. METHODS: A multi-centre randomized controlled trial comparing MRT with CBT was conducted among 122 patients with CFS diagnosed using the 1994 criteria of the Centers for Disease Control and Prevention and aged between 18 and 60 years. The societal costs (healthcare costs, patient and family costs, and costs for loss of productivity), fatigue severity, quality of life, quality-adjusted life-year (QALY), and cost-effectiveness ratios (ICERs) were measured over a follow-up period of one year. The main outcome of the cost-effectiveness analysis was fatigue measured by the Checklist Individual Strength (CIS). The main outcome of the cost-utility analysis was the QALY based on the EuroQol-5D-3L utilities. Sensitivity analyses were performed, and uncertainty was calculated using the cost-effectiveness acceptability curves and cost-effectiveness planes. RESULTS: The data of 109 patients (57 MRT and 52 CBT) were analyzed. MRT was significantly more effective in reducing fatigue at 52 weeks. The mean difference in QALY between the treatments was not significant (0.09, 95% CI: -0.02 to 0.19). The total societal costs were significantly higher for patients allocated to MRT (a difference of €5,389, 95% CI: 2,488 to 8,091). MRT has a high probability of being the most cost effective, using fatigue as the primary outcome. The ICER is €856 per unit of the CIS fatigue subscale. The results of the cost-utility analysis, using the QALY, indicate that the CBT had a higher likelihood of being more cost-effective. CONCLUSIONS: The probability of being more cost-effective is higher for MRT when using fatigue as primary outcome variable. Using QALY as the primary outcome, CBT has the highest probability of being more cost-effective. TRIAL REGISTRATION: ISRCTN77567702.

A biopsychosocial primary care intervention (Back on Track) versus primary care as usual in a subgroup of people with chronic low back pain: protocol for a randomised, controlled trial.

INTRODUCTION: Multidisciplinary biopsychosocial interventions are effective at improving functional disability in people with chronic low back pain. However, these interventions are often expensive and have long waiting times before treatment starts. Therefore, implementing biopsychosocial interventions in primary care settings may be of interest. Because people with chronic low back pain show different biopsychosocial profiles, they might respond differently to specific interventions. RESEARCH QUESTIONS: This study will investigate the difference in (cost) effectiveness between a biopsychosocial primary care intervention, Back on Track, and primary care physiotherapy as usual in a subgroup of adults with chronic low back pain. DESIGN: Double-blind, multicentre (n = 8), randomised, controlled trial. PARTICIPANTS: Eighty-six adults with chronic low back pain, aged 18 to 65 years, experiencing low to moderate levels of disability and in whom the contributing role of psychosocial factors to this disability is restricted. INTERVENTION: The Back on Track intervention: four individual and eight group sessions, based on biopsychosocial approaches from multidisciplinary pain rehabilitation programs and provided by trained physiotherapists. CONTROL: Primary care physiotherapy as usual. MEASUREMENTS: The primary outcome is functional disability (Quebec Back Pain Disability Scale) at post treatment, and 3-month and 12-month follow-up. Secondary measures are: credibility and expectancy, anxiety and depression, catastrophising, pain intensity, kinesiophobia, self-efficacy, participant's global perceived effect, cost-effectiveness, and cost-utility estimated with cost diaries and quality-adjusted life years. ANALYSIS: Linear mixed models using an intention-to-treat principle. Incremental cost-effectiveness and cost-utility ratios will be calculated and plotted on a cost-effectiveness plane. DISCUSSION: This study will provide useful information on a biopsychosocial intervention for chronic low back pain in primary care settings.

Energy Expenditure during Functional Daily Life Performances in Patients with Fibromyalgia.

OBJECTIVE: The objective of this study was to evaluate whether patients with fibromyalgia FM need more oxygen and more time to complete a walking and stair-climbing task than healthy volunteers and perceive the performance of these tasks as more strenuous. Furthermore, it was evaluated whether a less efficient performance is more pronounced in patients reporting a higher level of fear of movement. METHODS: Thirty patients with FM and 30 matched healthy volunteers completed a 500-meter walking and a stair-climbing task (60 steps) while wearing a mobile gas analyzing unit. Mean and total oxygen consumption and time needed to complete each task were recorded. After both tasks, a Borg score was used to measure perceived exertion. Fear of movement was measured with the Tampa Scale for Kinesiophobia. RESULTS: Patients with FM needed more time to complete the walking and stair-climbing task and reported higher levels of exertion compared to healthy volunteers. However, the total oxygen consumption for performing both tasks was not different. In patients with FM, a higher level of fear of movement was associated with a higher perceived exertion after the walking task. Interestingly, a higher somatic focus is related to a lower mean oxygen consumption needed to perform the stair-climbing task. CONCLUSION: In conclusion, patients with FM perceive a walking and stair-climbing task as more strenuous than healthy controls, even though they walked slower and no differences in total O2 consumption during completion of both tasks were found.

Assessment of activity limitations and participation restrictions with persons with chronic fatigue syndrome: a systematic review.

PURPOSE: To summarize measurement instruments used to evaluate activity limitations and participation restrictions in patients with chronic fatigue syndrome (CFS) and review the psychometric properties of these instruments. METHOD: General information of all included measurement instruments was extracted. The methodological quality was evaluated using the COSMIN checklist. Results of the measurement properties were rated based on the quality criteria of Terwee et al. Finally, overall quality was defined per psychometric property and measurement instrument by use of the quality criteria by Schellingerhout et al. RESULTS: A total of 68 articles were identified of which eight evaluated the psychometric properties of a measurement instrument assessing activity limitations and participation restrictions. One disease-specific and 37 generic measurement instruments were found. Limited evidence was found for the psychometric properties and clinical usability of these instruments. However, the CFS-activities and participation questionnaire (APQ) is a disease-specific instrument with moderate content and construct validity. CONCLUSION: The psychometric properties of the reviewed measurement instruments to evaluate activity limitations and participation restrictions are not sufficiently evaluated. Future research is needed to evaluate the psychometric properties of the measurement instruments, including the other properties of the CFS-APQ. If it is necessary to use a measurement instrument, the CFS-APQ is recommended. IMPLICATIONS FOR REHABILITATION: Chronic fatigue syndrome (CFS). Chronic fatigue syndrome causes activity limitations and participation restrictions in one or more areas of life. Standardized, reliable and valid measurement instruments are necessary to identify these limitations and restrictions. Currently, no measurement instrument is sufficiently evaluated with persons with CFS. If a measurement instrument is needed to identify activity limitations and participation restrictions with persons with CFS, it is recommended to use the CFS-APQ in clinical practice and scientific research.