Job stress and chronic low back pain: incidence, number of episodes, and severity in a 4-year follow-up of the ELSA-Brasil Musculoskeletal cohort.

ABSTRACT: We investigated the association between job stress, as assessed by the effort-reward imbalance model, and the incidence of chronic low back pain (CLBP) over a 4-year period. A total of 1733 participants from the ELSA-Brasil Musculoskeletal cohort, who were free from LBP at baseline (2012-2014), were included. Episodes of LBP in the past 30 days, intensity, and the presence of disability were investigated in annual telephone follow-ups (2015-2018). Chronic LBP was defined as episodes of LBP lasting >3 months with at least moderate intensity. We analyzed the incidence of at least one episode of CLBP (yes/no), the number of CLBP episodes (0, 1, ≥2), and CLBP severity/disability (absent, nondisabling, severe/disabling). The association between these outcomes and tertiles of the effort-to-reward ratio, as well as each dimension of the effort-reward imbalance model, was investigated using multinomial logistic and Poisson regression models adjusting for sociodemographic and occupational variables. The cumulative incidence of CLBP over 4 years was 24.8%. High effort-reward imbalance increased the chances of experiencing multiple CLBP episodes and severe/disabling CLBP by 67% (95% confidence interval [CI]: 1.12-2.47) and 70% (95% CI: 1.14-2.53), respectively. High overcommitment increased the incidence of CLBP by 23% (95% CI: 1.01-1.50) and the chances of multiple CLBP episodes and severe/disabling CLBP by 67% (95% CI: 1.11-2.50) and 57% (95% CI: 1.05-2.34), respectively. These results indicate that exposure to job stress is associated with a higher incidence, a greater number of episodes, and increased severity of CLBP over a 4-year period. If this association is causal, measures aimed at reducing exposure to job stress are likely to alleviate the burden of CLBP.

Obesity and the risk of multiple or severe frequent knee pain episodes: a 4-year follow-up of the ELSA-Brasil MSK cohort.

BACKGROUND/OBJECTIVE: Knee pain is an important health problem due to its high prevalence, negative impact on daily activities and quality of life, and societal burden. While the link between excess weight and knee pain has been well-documented in the literature, many studies are limited to patients with osteoarthritis or use cross-sectional data. This longitudinal study investigated whether overweight and obesity were associated with the frequency and severity of frequent knee pain (FKP) episodes over 4 years in civil servants enrolled in the ELSA-Brasil MSK cohort. METHODS: Knee pain was assessed during baseline face-to-face interviews (2012-2014) and four yearly telephone follow-ups (2015-2019). Disabling FKP episodes or those of moderate to very severe intensity were classified as severe. Multinomial logistic regression models adjusted for confounders were used to test for associations in two participant groups: those with knee pain at baseline (prognosis cohort) and those without knee pain (incidence cohort). RESULTS: A total of 2644 participants were included: 54.2% female, mean age 55.8 (SD 8.8) years. In the incidence cohort (n = 1896), obesity increased the risk of one (OR: 1.63; 95% CI 1.13-2.37) and multiple FKP episodes (OR: 2.61; 95% CI 1.71-3.97), as well as the risk of non-severe (OR: 1.72; 95% CI 1.04-2.84) and severe FKP episodes (OR: 2.10; 95% CI 1.50-2.95). In the prognosis cohort (n = 748), obesity increased the risk of multiple (OR: 2.54; 95% CI 1.60-4.05) and severe FKP episodes (OR: 2.31; 95% CI 1.49-3.59). Overweight presented the same trends but fell short of significance. CONCLUSIONS: These results provide further support that overweight and obesity are important contributors to the incidence and worsening of FKP, and that weight management must be prioritized in multidisciplinary knee pain prevention and treatment programs to reduce the burden of musculoskeletal disorders.

Uncovering the Relationship Between Statins and Muscle Problems in the ELSA-Brasil MSK Cohort.

PURPOSE: To investigate the association between statins and muscle problems in a highly diverse sample of Brazilian civil servants. METHODS: We conducted a cross-sectional data analysis at baseline of the ELSA-Brasil MSK cohort. Pain was identified through self-reported symptoms in large muscle groups (lower back and/or hips/thighs). Muscle strength was assessed using the five-times-sit-to-stand (FTSTS) and handgrip tests, with weakness defined as the lowest and highest quintiles of age- and sex-stratified handgrip strength and FTSTS performance time, respectively. Multivariable logistic regression analyses were conducted to investigate the association between statin use and muscle pain and weakness. Secondary analyses explored the impact of different types of statins and their duration of use on the response variables. RESULTS: A total of 2156 participants (mean age 55.6 ± SD 8.9, 52.8% women) were included, of whom 21.1% were taking statins and 25.1% reported muscle pain. We found no significant association between statin use and muscle problems. Secondary analysis on different types of statins revealed an association between atorvastatin and muscle weakness, as measured by the five-times-sit-to-stand test (OR 1.94, 95% CI 1.12-3.37), but not by the handgrip test (OR 0.75, 95% CI 0.29-1.42). No evidence was found to support a link between the duration of statin treatment and muscle problems. CONCLUSIONS: This study challenges previous claims of an efficacy-effectiveness gap between experimental and observational literature on statins. The findings indicate that statin use does not contribute to muscular problems.

Racial inequalities in multimorbidity: baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

BACKGROUND: Evidence of multimorbidity has come mainly from high-income regions, while disparities among racial groups have been less explored. This study examined racial differences in multimorbidity in the multiracial cohort of the Longitudinal Study of Adult Health (Estudo Longitudinal de Saúde do Adulto), ELSA-Brasil. METHODS: The study examined baseline (2008-2010) data for 14 099 ELSA-Brasil participants who self-reported being white, mixed-race, or black. A list of 16 morbidities was used to evaluate multimorbidity, operationalised by simple count into ≥ 2, ≥ 3, ≥ 4, ≥ 5 and ≥ 6 morbidities, in addition to evaluating the number of coexisting conditions. Prevalence ratios (PR) were estimated from logistic models and a quantile model was used to examine racial differences graphically in the distribution quantiles for the number of morbidities. RESULTS: Overall prevalence of multimorbidity (≥ 2 morbidities) was 70% and, after controlling for age and sex, was greater among mixed-race and black participants - by 6% (PR: 1.06; 95% CI: 1.03-1.08) and 9% (PR: 1.09; 95% CI: 1.06-1.12), respectively - than among white participants. As the cutoff value for defining multimorbidity was raised, so the strength of the association increased, especially among blacks: if set at ≥ 6 morbidities, the prevalence was 27% greater for those of mixed-race (PR: 1.27; 95% CI: 1.07-1.50) and 47% greater for blacks (PR: 1.47; 95% CI: 1.22-1.76) than for whites. The disparities were smaller in the lower morbidity distribution quantiles and larger in the upper quantiles, indicating a heavier burden of disease, particularly on blacks. CONCLUSIONS: Multimorbidity was common among adults and older adults in a Brazilian cohort, but important racial inequalities were found. Raising the cutoff point for defining multimorbidity revealed stronger associations between race/skin colour and multimorbidity, indicating a higher prevalence of multimorbidity among mixed-race and black individuals than among whites and that the former groups coexisted more often with more complex health situations (with more coexisting morbidities). Interventions to prevent and manage the condition of multimorbidity that consider the social determinants of health and historically discriminated populations in low- and middle-income regions are necessary.

Dose-response associations of clinical markers of obesity and duration of exposure to excess weight with chronic musculoskeletal pain: cross-sectional analysis at baseline of ELSA-Brasil Musculoskeletal cohort.

The objective of this study is to investigate the association of clinical markers of obesity and weight trajectories with chronic musculoskeletal pain (CMP). This is a cross-sectional study using baseline data from ELSA-Brasil MSK cohort. CMP was evaluated at nine body sites (neck, shoulders, upper back, elbows, lower back, wrists/hands, hips/thighs, knees, ankles/feet), and defined as pain lasting > 6 months in the past year. General and abdominal obesity levels were classified according to accepted cut-offs for body mass index (BMI), waist circumference (WC) and waist-height ratio (WHtR). Binomial and multinomial logistic regressions tested for associations with CMP at any site, at ≥ 3 sites (multisite) and in upper + lower limbs + axial skeleton (generalized). A total of 2899 participants (mean age 56.0 ± 8.93) were included, 55.0% reported CMP, 19.1% had multisite, and 10.3% had generalized CMP. After adjustments for sex, age, education, physical activity and depressive symptoms, nearly all the investigated markers of obesity were associated with any CMP, multisite and generalized CMP, with strongest associations being observed for general obesity level II/III: OR 2.08 (95% CI 1.45-2.99), OR 3.19 (95% CI 2.06-4.94) and OR 3.65 (2.18-6.11), respectively. Having excess weight currently or both at age 20 and currently was also associated with all CMP presentations. Associations of greater magnitude were consistently observed at higher obesity levels and longer exposures to excess weight (dose-response). These results may support the contribution of obesity-derived mechanical and inflammatory mechanisms of CMP, and indicate a role for the accumulation of exposure to excess weight across the adult life course.

Measurement properties of Portuguese-Brazil Western Ontario and McMaster Universities osteoarthritis index (WOMAC) for the assessment of knee complaints in Brazilian adults: ELSA-Brasil Musculoskeletal cohort.

Information on measurement properties of translated versions of the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index is still limited. This study investigated the internal consistency, test-retest reliability/agreement, construct validity, and floor and ceiling effects of Portuguese-Brazil WOMAC applied to civil servants at baseline of ELSA-Brasil Musculoskeletal cohort. Each measurement property was evaluated in the overall sample, in the subgroup reporting knee symptoms, and across different sociodemographic strata (except factorial analyses). Separate analyses were performed for pain, stiffness and function dimensions, considering the knee with the worst score (or right knee if same score in both knees). A total of 1740 participants were included (319 completed WOMAC on 2 occasions), mean age 56.0 (standard deviation = 8.9) years, 46.8% male, 42.1% had knee symptoms. In the overall sample, the range of results for WOMAC's dimensions were: internal consistency = cronbach alpha 0.92-0.98; test-retest reliability = intraclass correlation coefficient 0.85-0.97; standard error of measurement (SEM) = 1.38-5.86; smallest detectable change (SDC) = 3.84-16.25; lowest possible score = 38.8%-61.1% (floor effect present); highest possible score = 0.2%-0.9% (ceiling effect absent). Construct validity was confirmed by hypothesis testing and factorial analysis. Results were similar in the symptomatic group, except for higher SEM and SDC, and the absence of floor effects in pain and function dimensions. Portuguese-Brazil WOMAC showed good overall quality in a nonclinical setting. Variability in measurement properties across different strata of the population should be taken into consideration for the design of future studies using WOMAC.

Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials.

BACKGROUND: Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise. METHODS: In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers. RESULTS: We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics. CONCLUSIONS: This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups. PROTOCOL PUBLICATION: https://doi.org/10.1186/2046-4053-1-64.

Prevalence of pain and associated factors in Brazilian civil servants: an introductory analysis using baseline data from the ELSA-Brasil cohort.

INTRODUCTION: In Brazil, the prevalence and costs of pain will increase substantially with population ageing. Understanding of pain epidemiology is needed for the development of health care policies that can minimize this projected burden. OBJECTIVE: To investigate the prevalence of pain and associated factors at baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). METHODS: Data were collected in public institutions of higher education/research (2008-2010). Pain in the past 30 days and pain attributed to psychological distress ("with psychological attributions"-PPA) were evaluated by the Clinical Interview Schedule-Revised (CIS-R). The independent t-test and χ2 test investigated associations between sociodemographic/clinical factors and each pain episode. Multivariable analyses including age, sex, leisure-time physical activity, depression, and arthritis/rheumatism, and factors showing univariate associations at the P < 0.10 level, were performed. RESULTS: Fifteen thousand ninety-five civil servants were included (52.1 ± 9.1 years, 54.4% female). The prevalence of any pain was 62.4% (95% confidence interval 61.6%-63.2%), and of PPA was 22.8% (95% confidence interval 22.2%-23.5%). Factors associated with any pain and PPA in multivariable analyses included age (odds ratio [OR] 0.97), female sex (OR 1.86-2.01), moderate and vigorous leisure-time physical activity (OR 0.60-0.84), excessive drinking (OR 0.68-0.83), depressive symptoms (OR 1.28-1.96), anxiety symptoms (OR 1.63-2.45), sleep disturbance (OR 1.62-1.79), and arthritis/rheumatism (OR 1.32-2.18). Nonroutine nonmanual occupation (manual occupation as reference), body mass index, and smoking were independently associated with either any pain or PPA. CONCLUSION: This study provided preliminary information on the epidemiology of pain at baseline of the largest Latin American cohort on chronic noncommunicable diseases.

Correlates of a Recent History of Disabling Low Back Pain in Community-dwelling Older Persons: The Pain in the Elderly (PAINEL) Study.

OBJECTIVES: To investigate the correlates of a recent history of disabling low back pain (LBP) in older persons. MATERIALS AND METHODS: The Pain in the Elderly (PAINEL) Study was derived from the Frailty among Brazilian Older Adults (FIBRA) Network Study. Data were collected through face-to-face/telephone interviews and clinical examination. A series of logistic regressions assessed associations between a recent history of disabling LBP and sociodemographic, physical/lifestyle, and psychological factors. RESULTS: Of the 378 community-dwelling elders included in the study (age±SD, 75.5±6.1), 9.3% experienced LBP that was bad enough to limit or change their daily activities during the past year. Those reporting a recent history of disabling LBP were more likely to be women and under financial strain, to present poor self-rated health, overweight, multimorbidity, low physical activity level, fatigue, depressive symptomatology/diagnosis and fear beliefs, and to report decreased sleep time, prolonged sitting time, chronic pain (in location other than lower back), and frequently recurring LBP. The multivariate logistic regression analysis indicated that overweight (odds ratio [OR], 29.6; 95% confidence interval [CI], 2.3-391.0), low physical activity level (OR, 4.4; 95% CI, 1.3-15.4), fatigue (OR, 10.3; 95% CI, 2.4-43.4), depression diagnosis (OR, 4.9; 95% CI, 1.3-18.4), and frequently recurring LBP (OR, 4.6; 95% CI, 1.0-20.1) were independently associated with a recent history of disabling LBP. DISCUSSION: Our study supports the link between disabling LBP and other age-related chronic conditions in a middle-income country with a rapidly aging population.

Fixed-flexion knee radiography using a new positioning device produced highly repeatable measurements of joint space width: ELSA-Brasil Musculoskeletal Study (ELSA-Brasil MSK) / A radiografia do joelho em flexão fixa utilizando um novo posicionador produziu medidas da largura do espaço articular com alta repetibilidade: estudo ELSA-Brasil Musculoesquelético (ELSA-Brasil ME)

Abstract Objective: To describe the performance of a non-fluoroscopic fixed-flexion PA radiographic protocol with a new positioning device, developed for the assessment of knee osteoarthritis (OA) in Brazilian Longitudinal Study of Adult Health Musculoskeletal Study (ELSA-Brasil MSK). Material and methods: A test–retest design including 19 adults (38 knee images) was conducted. Feasibility of the radiographic protocol was assessed by image quality parameters and presence of radioanatomic alignment according to intermargin distance (IMD) values. Repeatability was assessed for IMD and joint space width (JSW) measured at three different locations. Results: Approximately 90% of knee images presented excellent quality. Frequencies of nearly perfect radioanatomic alignment (IMD ≤1 mm) ranged from 29% to 50%, and satisfactory alignment was found in up to 71% and 76% of the images (IMD ≤1.5 mm and ≤1.7 mm, respectively). Repeatability analyses yielded the following results: IMD [SD of mean difference = 1.08; coefficient of variation (%CV) = 54.68%; intraclass correlation coefficient (ICC) (95%CI) = 0.59 (0.34–0.77)]; JSW [SD of mean difference = 0.34–0.61; %CV = 4.48%–9.80%; ICC (95%CI) = 0.74 (0.55–0.85)–0.94 (0.87–0.97)]. Adequately reproducible measurements of IMD and JSW were found in 68% and 87% of the images, respectively. Conclusions: Despite the difficulty in achieving consistent radioanatomic alignment between subsequent radiographs in terms of IMD, the protocol produced highly repeatable JSW measurements when these were taken at midpoint and 10 mm from the medial extremity of the medial tibial plateau. Therefore, measurements of JSW at these locations can be considered adequate for the assessment of knee OA in ELSA-Brasil MSK.

Resumo Objetivo: Descrever o desempenho de um protocolo radiográfico em flexão fixa sem fluoroscopia em incidência PA com um novo posicionador, desenvolvido para a avaliação da osteoartrite de joelho (OA) no estudo ELSA-Brasil ME. Material e métodos: Fez-se um estudo de teste e reteste que incluiu 19 adultos (38 imagens de joelho). A viabilidade do protocolo radiográfico foi avaliada por meio de parâmetros de qualidade da imagem e presença de alinhamento radioanatômico de acordo com as medidas da distância intermarginal (DIM). Avaliaram-se a repetibilidade dos valores de DIM e do espaço articular (EA) em três locais diferentes. Resultados: Aproximadamente 90% das imagens de joelho apresentaram uma qualidade excelente. As frequências de imagens com alinhamento radioanatômico quase perfeito (DIM<1mm) variaram de 29% a 50%, e de alinhamento satisfatório (DIM<1,5mm e <1,7mm) de 71% a 76%, respectivamente. As análises de repetibilidade produziram os seguintes resultados: DIM [DP da média das diferenças = 1,08; coeficiente de variação (% CV) = 54,68%; coeficiente de correlação intraclasse (CCI) (IC 95%) = 0,59 (0,34 a 0,77)]; EA [DP da média das diferenças = 0,34 a 0,61; % CV = 4,48% a 9,80%; CCI (IC 95%) = 0,74 (0,55 a 0,85) a 0,94 (0,87 a 0,97]. Encontraram-se medidas adequadamente reprodutíveis de DIM e EA em 68% e 87% das imagens, respectivamente. Conclusões: Apesar da dificuldade de obter um alinhamento radioanatômico consistente entre radiografias repetidas em termos de DIM, o protocolo produziu medições de EA altamente repetíveis quando essas foram tomadas no ponto médio e a 10 mm da extremidade medial do platô tibial medial. Portanto, as medidas de EA nesses locais podem ser consideradas adequadas para a avaliação da OA de joelho no estudo ELSA-Brasil ME.

Fixed-flexion knee radiography using a new positioning device produced highly repeatable measurements of joint space width: ELSA-Brasil Musculoskeletal Study (ELSA-Brasil MSK).

OBJECTIVE: To describe the performance of a non-fluoroscopic fixed-flexion PA radiographic protocol with a new positioning device, developed for the assessment of knee osteoarthritis (OA) in Brazilian Longitudinal Study of Adult Health Musculoskeletal Study (ELSA-Brasil MSK). MATERIAL AND METHODS: A test-retest design including 19 adults (38 knee images) was conducted. Feasibility of the radiographic protocol was assessed by image quality parameters and presence of radioanatomic alignment according to intermargin distance (IMD) values. Repeatability was assessed for IMD and joint space width (JSW) measured at three different locations. RESULTS: Approximately 90% of knee images presented excellent quality. Frequencies of nearly perfect radioanatomic alignment (IMD ≤1mm) ranged from 29% to 50%, and satisfactory alignment was found in up to 71% and 76% of the images (IMD ≤1.5mm and ≤1.7mm, respectively). Repeatability analyses yielded the following results: IMD [SD of mean difference=1.08; coefficient of variation (%CV)=54.68%; intraclass correlation coefficient (ICC) (95%CI)=0.59 (0.34-0.77)]; JSW [SD of mean difference=0.34-0.61; %CV=4.48%-9.80%; ICC (95%CI)=0.74 (0.55-0.85)-0.94 (0.87-0.97)]. Adequately reproducible measurements of IMD and JSW were found in 68% and 87% of the images, respectively. CONCLUSIONS: Despite the difficulty in achieving consistent radioanatomic alignment between subsequent radiographs in terms of IMD, the protocol produced highly repeatable JSW measurements when these were taken at midpoint and 10mm from the medial extremity of the medial tibial plateau. Therefore, measurements of JSW at these locations can be considered adequate for the assessment of knee OA in ELSA-Brasil MSK.

Psychometric properties of Multidimensional Health Locus of Control - A and General Self-Efficacy Scale in civil servants: ELSA-Brasil Musculoskeletal Study (ELSA-Brasil MSK).

BACKGROUND: Health-related control and self-efficacy beliefs can be assessed in the general population using Multidimensional Health Locus of Control-A subscales (MHLC-A) and the General Self-Efficacy Scale (GSES), respectively. OBJECTIVE: To test construct validity, internal consistency, reliability (test-retest) and ceiling and floor effects of Portuguese-Brazil versions of MHLC-A and GSES. METHOD: Civil servants (N=2901) enrolled in a large Brazilian cohort were included. A new version of the GSES was produced (GSES-Brazil). Procedures for cross-cultural adaptation and testing of psychometric properties followed well-accepted international guidelines. RESULTS: Confirmatory factor analyses yielded the following indices: MHLC-A (tridimensional model): χ2[df]=223.45[132], p-value <0.01; CFI=0.87; TLI=0.85; RMSEA=0.07 (0.07-0.08); WRMR=3.00. GSES-Brazil (unidimensional model): χ2[df]=788.60[35], p-value <0.01; CFI=0.95; TLI=0.94; RMSEA=0.09 (0.08-0.09); WRMR=2.50. Cronbach's alpha coefficients and Intraclass Correlation Coefficients (ICC2,1) ranged from 0.57 (0.54-0.59) and 0.57 (0.47-0.65) for MHLC-A internality to 0.80 (0.79-0.81) and 0.71 (0.66-0.77) for GSES-Brazil, respectively. There was no evidence of ceiling and floor effects. Convergent validity analyses provided further support for construct validity of both scales. CONCLUSION: These findings support the use of the newly developed version of GSES-Brazil for the assessment of general self-efficacy of adult Brazilians. Internal consistency was lower than ideal for MHLC-A, indicating these subscales may need further refinements to provide a more psychometrically sound measure of control beliefs.

Psychometric properties of Multidimensional Health Locus of Control - A and General Self-Efficacy Scale in civil servants: ELSA-Brasil Musculoskeletal Study (ELSA-Brasil MSK)

Abstract Background Health-related control and self-efficacy beliefs can be assessed in the general population using Multidimensional Health Locus of Control-A subscales (MHLC-A) and the General Self-Efficacy Scale (GSES), respectively. Objective To test construct validity, internal consistency, reliability (test-retest) and ceiling and floor effects of Portuguese-Brazil versions of MHLC-A and GSES. Method Civil servants (N=2901) enrolled in a large Brazilian cohort were included. A new version of the GSES was produced (GSES-Brazil). Procedures for cross-cultural adaptation and testing of psychometric properties followed well-accepted international guidelines. Results Confirmatory factor analyses yielded the following indices: MHLC-A (tridimensional model): χ2[df]=223.45[132], p-value <0.01; CFI=0.87; TLI=0.85; RMSEA=0.07 (0.07-0.08); WRMR=3.00. GSES-Brazil (unidimensional model): χ2[df]=788.60[35], p-value <0.01; CFI=0.95; TLI=0.94; RMSEA=0.09 (0.08-0.09); WRMR=2.50. Cronbach’s alpha coefficients and Intraclass Correlation Coefficients (ICC2,1) ranged from 0.57 (0.54-0.59) and 0.57 (0.47-0.65) for MHLC-A internality to 0.80 (0.79-0.81) and 0.71 (0.66-0.77) for GSES-Brazil, respectively. There was no evidence of ceiling and floor effects. Convergent validity analyses provided further support for construct validity of both scales. Conclusion These findings support the use of the newly developed version of GSES-Brazil for the assessment of general self-efficacy of adult Brazilians. Internal consistency was lower than ideal for MHLC-A, indicating these subscales may need further refinements to provide a more psychometrically sound measure of control beliefs.

Attitudes and beliefs of Brazilian physical therapists about chronic low back pain: a cross-sectional study / Atitudes e crenças de fisioterapeutas brasileiros em relação à dor lombar crônica: um estudo transversal

OBJECTIVES: To measure the attitudes and beliefs of Brazilian physical therapists about chronic low back pain and to identify the sociodemographic characteristics that are more likely to influence these attitudes and beliefs. METHODS: We conducted a cross-sectional study with 100 Brazilian physical therapists who routinely work with chronic low back pain patients. The attitudes and beliefs were measured by the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT) and the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS). Multivariate linear regression models were built to identify sociodemographic characteristics that could be associated with physical therapists' attitudes and beliefs. RESULTS: Mean scores on the biomedical and biopsychosocial factors of PABS.PT were 27.06 (SD 7.19) and 24.34 (SD 6.31), respectively, and the mean score on HC-PAIRS was 45.45 (SD 10.45). The score on PABS.PTbiomedical was associated with gender and years of professional experience. No variable was associated with the score on PABS.PTbiopsychosocial. The score on HC-PAIRS was significantly associated with the number of back pain patients seen by the physical therapist each month. These results indicate that male and less experienced physical therapists tend to follow a biomedical approach to the treatment of chronic low back pain patients, and that the lower the professional experience the stronger the belief in the relationship between pain and disability. CONCLUSIONS: Brazilian physical therapists are uncertain of the factors involved in the development and maintenance of chronic low back pain and about the relationship between pain and disability in these patients.

OBJETIVOS: Avaliar as atitudes e crenças de fisioterapeutas brasileiros sobre a dor lombar crônica e identificar características sociodemográficas que as influenciam. MÉTODOS: Este estudo transversal incluiu 100 fisioterapeutas brasileiros que atendem pacientes com dor lombar crônica em sua rotina clínica. As atitudes e crenças foram avaliadas pela Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT) e Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS). Foram construídos modelos de regressão linear multivariada para verificar as possíveis características sociodemográficas que poderiam estar associadas com as atitudes e crenças dos fisioterapeutas. RESULTADOS: Os escores médios dos fatores biomédico e comportamental da PABS.PT foram 27,06 (DP 7,19) e 24,34 (DP 6,31), respectivamente, e o escore médio da HC-PAIRS foi 45,45 (DP 10,45). O escore do PABS.PT Fator biomédico foi associado com gênero e anos de experiência profissional. Já o escore do PABS.PT Fator comportamental não foi associado com nenhuma variável. O escore do HC-PAIRS foi significativamente associado com o número de pacientes com dor lombar atendido por mês. Esses resultados indicam que fisioterapeutas experientes tendem a seguir uma abordagem biomédica no tratamento de pacientes com dor lombar crônica. Além disso, quanto menor a experiência profissional, mais forte é a crença na relação entre dor e incapacidade. CONCLUSÕES: Os fisioterapeutas brasileiros mostram-se incertos acerca dos fatores que envolvem o desenvolvimento e a manutenção da dor lombar crônica e também sobre a relação entre dor e incapacidade nesses pacientes. Isso põe em questão as atitudes e práticas em relação ao manejo dos pacientes com dor lombar crônica no Brasil.

Prevalence of chronic musculoskeletal disorders in elderly Brazilians: a systematic review of the literature.

BACKGROUND: Population ageing is a worldwide phenomenon that has recently challenged public healthcare systems. The knowledge of the burden of chronic musculoskeletal disorders in elders is still limited, particularly in the developing world. This systematic review aimed to investigate the prevalence of chronic musculoskeletal disorders in elderly Brazilians. METHODS: A comprehensive literature search was performed in five electronic databases (from inception to January 2012) and completed by additional searches in reference lists. Two review authors independently selected the eligible studies and extracted data on participants' characteristics and rates of chronic musculoskeletal disorders. One review author extracted methodological quality data. We performed a critical synthesis of the results, which were grouped into the diagnoses "chronic musculoskeletal pain" or "specific musculoskeletal diagnoses". RESULTS: Twenty five studies reporting on a total of 116,091 elderly Brazilians were included. Eight studies (32%) were of high methodological quality. There was a large variation in the measure of prevalence used by individual studies and in their definition of chronic pain. Prevalence estimates reached 86% for chronic musculoskeletal pain in any location. Studies investigating multiple pain sites found the lower limb and the spine to be the most prevalent complaints (50% each). Arthritis and rheumatism (including osteoarthritis) were the most prevalent specific musculoskeletal diagnoses (9% to 40%), followed by herniated disc (6% to 27%). CONCLUSIONS: Despite the growth of the elderly population worldwide, high-quality research on the burden of chronic musculoskeletal disorders in the elderly is still scarce. Future healthcare research focusing on this age group should be a priority in developing countries since their public healthcare systems are not yet fully prepared to accommodate the needs of an aging population.

Attitudes and beliefs of Brazilian physical therapists about chronic low back pain: a cross-sectional study.

OBJECTIVES: To measure the attitudes and beliefs of Brazilian physical therapists about chronic low back pain and to identify the sociodemographic characteristics that are more likely to influence these attitudes and beliefs. METHODS: We conducted a cross-sectional study with 100 Brazilian physical therapists who routinely work with chronic low back pain patients. The attitudes and beliefs were measured by the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT) and the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS). Multivariate linear regression models were built to identify sociodemographic characteristics that could be associated with physical therapists' attitudes and beliefs. RESULTS: Mean scores on the biomedical and biopsychosocial factors of PABS.PT were 27.06 (SD 7.19) and 24.34 (SD 6.31), respectively, and the mean score on HC-PAIRS was 45.45 (SD 10.45). The score on PABS.PT(biomedical) was associated with gender and years of professional experience. No variable was associated with the score on PABS.PT(biopsychosocial). The score on HC-PAIRS was significantly associated with the number of back pain patients seen by the physical therapist each month. These results indicate that male and less experienced physical therapists tend to follow a biomedical approach to the treatment of chronic low back pain patients, and that the lower the professional experience the stronger the belief in the relationship between pain and disability. CONCLUSIONS: Brazilian physical therapists are uncertain of the factors involved in the development and maintenance of chronic low back pain and about the relationship between pain and disability in these patients.

Can we predict response to the McKenzie method in patients with acute low back pain? A secondary analysis of a randomized controlled trial.

PURPOSE: To evaluate whether patients' treatment preferences, characteristics, or symptomatic response to assessment moderated the effect of the McKenzie method for acute low back pain (LBP). METHODS: This study involved a secondary analysis of a previous RCT on the effect of adding the McKenzie method to the recommended first-line care for patients with acute non-specific LBP. 148 patients were randomized to the First-line Care Group (recommended first-line care alone) or the McKenzie Group (McKenzie method in addition to the first-line care) for a 3-week course of treatment. The primary outcome was pain intensity at 3 weeks. The ability of six patient characteristics to identify those who respond best to McKenzie method was assessed using interaction terms in linear regression models. RESULTS: The six investigated potential effect modifiers for response to the McKenzie method did not predict a more favorable response to this treatment. None of the point estimates for effect modification met our pre-specified criterion of clinical importance of a 1 point greater improvement in pain. For five of the six predictors, the 95% CI did not include our criterion for meaningful clinical improvement. CONCLUSION: We were unable to find any clinically useful effect modifiers for patients with acute LBP receiving the McKenzie method.

Clinimetric testing of two instruments that measure attitudes and beliefs of health care providers about chronic low back pain.

BACKGROUND: There are no clinimetrically tested instruments for measuring attitudes and beliefs of health care providers with regards to chronic low back pain in Brazil. OBJECTIVES: To translate and cross-culturally adapt the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT) into Brazilian-Portuguese and to test the clinimetric properties of the Brazilian-Portuguese versions of the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the PABS.PT. METHODS: The PABS.PT was cross-culturally adapted following the recommendations of current guidelines. The PABS.PT and the HC-PAIRS were clinimetrically tested in 100 physical therapists who routinely treat patients with low back pain in their clinical practice. The internal consistency, construct validity and ceiling and floor effects were tested using only baseline values from the participants while reproducibility was evaluated in a test-retest design with a seven-day interval. RESULTS: Both scales demonstrated adequate levels of internal consistency (Cronbach's alpha ranging from 0.67 to 0.74). Their reproducibility ranged from moderate to substantial (Intraclass Correlation Coefficient2,1 ranging from 0.70 to 0.84; Standard Error of the Measurement ranging from 3.48 to 5.06). The validity coefficients of the scales ranged from weak to moderate (Pearson's correlation coefficient ranging from 0.19 to 0.62). No ceiling or floor effects were detected. CONCLUSIONS: The results of the present study indicate that both PABS.PT and HC-PAIRS are reproducible scales for the measurement of attitudes and beliefs towards chronic low back pain in Brazilian physical therapists.

Testes clinimétricos de dois instrumentos que mensuram atitudes e crenças de profissionais de saúde sobre a dor lombar crônica / Clinimetric testing of two instruments that measure attitudes and beliefs of health care providers about chronic low back pain

CONTEXTUALIZAÇÃO: Não existem instrumentos clinimetricamente testados que mensuram atitudes e crenças de profissionais de saúde sobre a dor lombar crônica no Brasil. OBJETIVOS: Traduzir e adaptar transculturalmente a escala Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT) para o português-brasileiro e avaliar as propriedades clinimétricas das versões em português-brasileiro da Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) e da PABS.PT. MÉTODOS: A PABS.PT foi adaptada transculturalmente seguindo recomendações das diretrizes existentes. Em seguida, as versões em português-brasileiro da PABS.PT e da HC-PAIRS foram clinimetricamente testadas em 100 fisioterapeutas que rotineiramente trabalhavam com pacientes portadores de dor lombar em sua prática clínica. A consistência interna, validade do construto e efeitos de teto e piso foram testados utilizando somente as respostas dos participantes na linha de base do estudo, e a reprodutibilidade foi testada em um delineamento de teste-reteste com intervalo de sete dias. RESULTADOS: Os instrumentos apresentaram valores adequados de consistência interna (Alfa de Cronbach variando entre 0,67 e 0,74). Sua reprodutibilidade variou de moderada a substancial (Coeficiente de Correlação Intraclasse tipo 2,1 variando entre 0,70 e 0,84; Erro-Padrão da Medida variando entre 3,48 e 5,06). Os índices de correlação entre os instrumentos variaram de fraco a moderado (Índice de Correlação de Pearson variando entre 0,19 e 0,62). Não foram detectados efeitos de teto e piso nos instrumentos. CONCLUSÕES: Os resultados do presente estudo indicam que ambas as escalas PABS.PT e HC-PAIRS são instrumentos reprodutíveis para mensurar as atitudes e crenças relacionadas à dor lombar crônica em profissionais de saúde brasileiros.

BACKGROUND: There are no clinimetrically tested instruments for measuring attitudes and beliefs of health care providers with regards to chronic low back pain in Brazil. OBJECTIVES: To translate and cross-culturally adapt the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS.PT) into Brazilian-Portuguese and to test the clinimetric properties of the Brazilian-Portuguese versions of the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the PABS.PT. METHODS: The PABS.PT was cross-culturally adapted following the recommendations of current guidelines. The PABS.PT and the HC-PAIRS were clinimetrically tested in 100 physical therapists who routinely treat patients with low back pain in their clinical practice. The internal consistency, construct validity and ceiling and floor effects were tested using only baseline values from the participants while reproducibility was evaluated in a test-retest design with a seven-day interval. RESULTS: Both scales demonstrated adequate levels of internal consistency (Cronbach's alpha ranging from 0.67 to 0.74). Their reproducibility ranged from moderate to substantial (Intraclass Correlation Coefficient2,1 ranging from 0.70 to 0.84; Standard Error of the Measurement ranging from 3.48 to 5.06). The validity coefficients of the scales ranged from weak to moderate (Pearson's correlation coefficient ranging from 0.19 to 0.62). No ceiling or floor effects were detected. CONCLUSIONS: The results of the present study indicate that both PABS.PT and HC-PAIRS are reproducible scales for the measurement of attitudes and beliefs towards chronic low back pain in Brazilian physical therapists.

Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review.

Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.