| 1. |
- Dufvenberg, Marlene, 1961-
(författare)
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Adolescent Idiopathic Scoliosis : Postural Stability, Prognostic factors and Impact of Conservative Treatments on Radiologic, Clinical and Self-Reported Outcomes
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional distortion of spinal curvature of unknown cause that develops during puberty. If the frontal plane curvature exceeds a Cobb angle of 24°, full-time bracing is recommended to prevent curve progression, negative health consequences or need for surgery. However, many patients decline full-time bracing, and limited evidence exists regarding alternative conservative treatments. Increasing knowledge of risk factors enables better identification of high-risk patients, thereby reducing the risk of over- or undertreatment. The overall aim of this thesis was to evaluate evidence of association between scoliosis and postural stability to inform a potential treatment target, to investigate the effectiveness of three alternative conservative treatments for patients who declined full-time bracing, and to develop a prognostic model for future risk of increased curvature in AIS. Methods: Data collection is based on one systematic literature review and meta-analysis, and one randomised controlled trial (RCT) for patients with AIS. In Paper I, literature was reviewed, and utilized posturography data to assess static postural stability to identify potential differences between patients with AIS and the control group (CON). In Papers II and III, patients were randomly assigned to either physical activity combined with hypercorrective Boston scoliosis night brace (NB), scoliosis-specific exercises (SSE), or a control group with physical activity alone (PA). Effects on trunk rotation, Cobb angle, self-reported physical activity, spinal appearance, and health-related quality of life were evaluated. Likewise, adherence, capability, and motivation in performing self-managed treatment were assessed. Follow-up was conducted at 6 months intervals until endpoint. The endpoint was defined as non-progression if the curvature increased by 6° or less at skeletal maturity, i.e., less than 1cm of growth over 6 months, or progression if the curvature increased by more than 6° before skeletal maturity. In Paper IV, data from the RCT were used for a longitudinal cohort analysis, developing and validating a prognostic model using Cox Proportional Hazards survival analysis. Results: Paper I found reduced postural stability in AIS patients compared to CON with increased sway area, mediolateral and anteroposterior range, and a posterior shift in the sagittal plane. The RCT included 135 individuals, mean age of 12.7 years (SD1.4) and Cobb angle of 31° (SD5.3). At 6 months, patients reported high adherence (72-95%) and motivation (65-92%) to the treatment, particularly in the NB group. Both the SSE and PA groups increased physical activity levels compared to the NB group. At endpoint, adherence remained adequate, but better in the NB and PA groups compared with the SSE group (50-89%). Adherence increased with higher capability and motivation, which explained 53% of the variance in adherence at endpoint. The SSE group had higher proportion of moderate problems in mobility and usual activities than the NB and PA groups, with no other clinically relevant between-group differences. The prognostic model (n=127) for curve progression showed acceptable discriminative ability (0.791), with risk factors including skeletal immaturity, larger major curve, and worsening spinal appearance. The model was adjusted for treatment exposure, as NB reduced the risk of curve progression. Conclusions: Patients with AIS have decreased postural stability with a posterior positional shift. Treatment evaluation at endpoint showed few between-group differences. However, the SSE group had higher proportion of moderate problems in mobility and usual activities compared to the other groups. Treatment adherence was adequate, but better in the NB and PA groups. Higher capability and motivation increased long-term adherence to the treatment. The treatment alternatives could be considered as the first option following a clinical decision on treatment. Including self-reported spinal appearance as a risk factor in the prognostic model may be clinically important for predicting which patients are at risk of curve progression.
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| 2. |
- Schröder, Karin, 1966-
(författare)
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Implementing BetterBack – a Best Practice Physiotherapy Healthcare Model for Low Back Pain : Clinician and Patient Evaluation
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Low back pain (LBP) occurs in all ages, and first-line treatment by physiotherapists (PTs) is common. However, national evidence-based LBP clinical guidelines are still lacking in Sweden. To facilitate guideline uptake, we developed and with a multifaceted strategy implemented a best practice physiotherapy healthcare model (BetterBack☺ MoC) with the aim of supporting management of LBP in primary care. The overall aim of this thesis was to evaluate a multifaceted implementation strategy and a best practice physiotherapy healthcare model for LBP.Methods: This thesis is based on one methodological study and three experimental trials with PTs and patients with LBP. In Paper I a mixed method design was used to translate, tailor, validate and feasibility-test the Determinants of Implementation Behaviour Questionnaire (DIBQ). This tailored DIBQ Questionnaire (DIBQ-t) was used to evaluate potential barriers/facilitators during the implementation process together with evaluation of PTs’ confidence, attitudes and beliefs in managing LBP. In a stepped cluster randomised controlled trial, PTs and their patients in three clusters were allocated to intervention group (after implementation of BetterBack☺ MoC) or control group (routine physiotherapy care). The proportions of guideline-adherent care were compared between groups (Paper III). This evaluation was based on PTs’ adherence to eight clinical practice recommendations and three clinical practice quality indices (CPQI). The overall CPQI containing the five most prioritised recommendations are: no referral to specialist care; no referral to medical imaging for benign LBP; use of educational interventions; use of exercise interventions; and no use of non-evidence-based physiotherapy. Finally, in Paper IV patient-reported outcome measures (PROMs) were compared between intervention (after the implementation of BetterBack☺ MoC) and routine care. In Paper IV an additional secondary analysis was performed, comparing PROMs based on whether or not PTs had delivered care that met all five criteria of the overall CPQI or not.Results: A tailored, feasible and valid questionnaire was developed, DIBQ-t to be used for evaluation of the implementation of LBP primary care programmes. After implementation workshop, PTs’ (n = 116) confidence increased, and PTs’ attitudes and beliefs shifted towards a more biopsychosocial orientation. PTs had high expectations of the BetterBack☺ MoC, which decreased after using the MoC. When evaluating received treatment for 500 patients with LBP, a more frequent delivery of guideline-adherent care was seen after implementation (n = 278) compared to routine care (n = 222). The overall CPQI containing the five prioritised recommendations was fulfilled in 59% of all patients in intervention versus 26% in routine care group. Analysis of adherence to specific recommendations showed a significantly improved use of stratification of number of PT visits and patient educational interventions, frequent use of exercise was maintained, and use of non-evidence-based treatment and medical imaging decreased after implementation. The primary outcome, i.e. referral to specialist consultation, was low in both groups, with no between-group differences. After implementation of the BetterBack☺ MoC, no between-group differences in PROMs were seen except for greater satisfaction with LBP care, greater improvement in illness perception and better health-related quality of life, compared with routine care. However, when PTs’ care adhered to all five CPQI criteria, a greater improvement of most patient-reported outcomes was seen compared to patient care that did not adhere to all five CPQI criteria. Conclusions: The implementation of a best practice physiotherapy healthcare model (BetterBack☺ MoC) for LBP improved both clinician and patient outcomes. PTs increased use of guideline-adherent care, confidence and biopsychosocial orientation in managing LBP. Patients reported improved satisfaction, illness perception and health-related quality of life. The implementation did not decrease referral to specialist consultation from an initial low level; nor did it improve patients’ disability and pain more than routine care. However, when guideline-adherent care was fulfilled, most PROMs improved. It is therefore important to highlight the importance of guideline-based primary care for improving patient-reported LBP outcomes.
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| 3. |
- Fors, Maria, 1987-
(författare)
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Best Practice Physiotherapy for Patients with Low Back Pain in Primary Care : Clinical Outcomes and Explanatory Factors
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Clinical practice guidelines provide general recommendations informing best practice physiotherapy for low back pain (LBP). Despite increased research on LBP, the recommendations have barely changed over the last few decades and the burden of LBP remains. New research strategies have been suggested to further understand the complexity of factors influencing recovery of LBP. Several mechanisms are expected to underpin the benefits of physiotherapy care. How different factors influence and explain treatment outcome in patients in different phases of primary care pathway needs to be better understood for the development of better targeted LBP interventions.The overall aim of this thesis was to investigate if and how best practice physiotherapy primary care for patients with LBP can improve clinical outcome.Methods: The four papers in the thesis are based on two randomised controlled trials (RCT) evaluating best practice physiotherapy for patients with LBP in different phases of the primary care pathway reflecting the variation of patients’ needs. Two papers investigated pre-surgery physiotherapy compared to being on a waiting-list in patients with degenerative lumbar spine disorders who are surgical candidates (n = 197). Effects on walking ability and quadriceps femoris strength were evaluated. Associations between the pre-surgery physical factors with 1-year post-surgery physical activity (PA) level were analysed using multiple linear regression. The dose-response relationship was investigated comparing the effects of attending ≤11 treatment sessions with ≥12 treatment sessions. Multiple mediation analyses and conditional process analyses were used to explore physical and psychosocial factors as mediators and patients’ treatment expectations as a moderator of the treatment’s effects on disability, back pain intensity, health-related quality of life (HRQoL), and self-rated health.Two papers were based on a stepped cluster RCT, where a physiotherapy primary healthcare model for LBP (the BetterBack MoC) was regionally implemented. Patients seeking care for LBP were allocated to either the BetterBack MoC (after implementation) or to routine care (before implementation) (n = 467). In a prospective cohort study within the RCT, the associations between patients’ initial illness perceptions and outcomes in disability, back pain intensity, HRQoL, and self-care enablement (i.e., perceived ability to understand and cope with LBP) after 3 and 12 months were explored using stepwise linear regression. Single mediation analyses were used to test whether a priori hypothesised patients’ illness perceptions and self-care enablement at 3 months mediated effects in disability and pain at 6 months of care according to the BetterBack MoC compared to routine care. Exploratory mediation analyses were also used to compare guideline-adherent care with non-adherent care. Guideline-adherent care was defined as care that included education and exercise interventions and did not include non-evidence-based interventions, referral to specialist care, or imaging.Results: Small positive effects from pre-surgery physiotherapy were seen in walking ability and quadriceps femoris strength. No clear dose-response relationship could be demonstrated when comparing the effects of ≤11 treatment sessions with ≥12. Pre-surgery physical outcome measures together explained 27.5% of the variation in PA level 1-year post-surgery, mainly explained by the pre-surgery PA level. The effect of the pre-surgery physiotherapy on patients’ PA level partly explained the treatment’s effect on self-rated health. Furthermore, among biopsychosocial factors, self-efficacy related to activities of daily living (ADL) partly explained the effect on all outcomes. PA related fear avoidance beliefs partly explained the effects on pain and self-rated health. Patients’ treatment expectations moderated the effect in all outcomes. High expectations had a positive moderating effect, while expectation of full recovery had a suppressive effect. In patients seeking physiotherapy for LBP, negative initial prognosis and treatment expectations were associated with worse scores in several outcomes at 3- and 12-month follow-ups. Patients’ illness perceptions and self-care enablement did not explain the effects of care after implementing the BetterBack MoC. This was mainly due to the BetterBack MoC not having superior effects over routine care on the hypothesised mediators. Illness perceptions and self-care enablement at 3 months were associated with disability and pain at 6 months. Further, these factors partly explained the effects of guideline-adherent care in disability and pain.Conclusions: Patients’ illness perceptions, self-care enablement, ADL self-efficacy, and PA related fear-avoidance beliefs were supported to be potential factors explaining the effect on clinical outcomes of best practice physiotherapy for LBP in primary care. Patients’ initial expectations regarding the prognosis and treatment may influence prospective outcomes including patients’ self-care enablement. More specifically, pain and disability outcomes of best practice physiotherapy for patients seeking care for LBP may improve by targeting patients’ illness perceptions and self-care enablement. Patients who are surgical candidates can increase their physical capacity and walking related performance through best practice physiotherapy. In this pre-surgery phase, the treatment should include targeting patients’ ADL self-efficacy, PA related fear-avoidance beliefs, and PA level for improved disability, pain, and HRQoL.
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| 4. |
- Abbott, Allan, 1978-
(författare)
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Physiotherapeutic rehabilitation and lumbar fusion surgery
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Over the last two decades, the economic costs and rates of lumbar fusion surgery for chronic low back pain has risen dramatically in western industrialized countries. Data from the Swedish National Spine Register suggest that 25% of patients experience unimproved pain and up to 40% are not satisfied with the outcome of lumbar fusion surgery. Thus, there is a definite need to optimize the selection and management of patients to improve lumbar fusion outcomes. Aim: To investigate the role of biopsychosocial factors in explaining disability and health related quality of life in chronic low back pain patients before and after lumbar fusion surgery and to evaluate the effectiveness of post-operative rehabilitation regimes. Methods: At total of 107 patients were recruited, aged 18 to 65 years, selected for lumbar fusion due to 12 months of symptomatic back and/or leg pain due to spinal stenosis, degenerative/isthmic spondylolisthesis or degenerative disc disease. Measures of disability, health related quality of life, pain, mental health, fear of movement/(re)injury, self-efficacy, outcome expectancy, pain coping styles, work status, health care use, analgesic use and sickness leave were collected with self-rated questionnaires at baseline (Studies I-IV), 3, 6, 12 months (Study II) and 2-3 years after surgery (Studies II-III). In Studies II-IV, patients were randomised to psychomotor therapy (N=53) or exercise therapy (N=54) implemented during the first 3 post-operative months. Semi-structured interviews were conducted 3-6 months after surgery on 20 patients including 10 from each rehabilitation group to investigate experiences of back problems before and after surgery, post-operative recovery and expectations of rehabilitation analysed in terms of the International Classification of Functioning, Disability and Health (Study IV). Results: Approximately 50% of the variability in baseline disability and 40% of the variability in baseline health related quality of life could be explained by psychological variables. In particular, catastrophizing, control over pain, self-efficacy and outcome expectancy had significant mediation roles (Study I). For the short and long term outcome of lumbar fusion surgery, post-operative psychomotor therapy is significantly more effective than exercise therapy with approximately 10-20% better outcome in measures of disability, fear of movement/(re)injury, pain catastrophizing, self-efficacy, outcome expectancy sickness leave, health care utilization and return to work (Study II). A model with good outcome predictive performance which significantly predicts disability, back pain and health related quality of life outcomes 2-3 year after lumbar fusion surgery, was shown to involve pre-operative screening of disability, leg pain intensity, mental health, fear of movement/(re)injury, outcome expectations, catastrophizing, control over pain and the implementation of post-operative psychomotor therapy (Study III). Lumbar fusion patient s experiences of back problems before and after the operation as well as experiences of recovery and outcome expectations correspond well with the content of outcomes measures used in the study suggesting good content validity (Study IV). Conclusion: Psychological factors strongly influence levels of disability and health related quality of life in lumbar fusion candidates as well as predicts post-operative outcomes. Early post-operative rehabilitation focusing on cognition, behaviour and motor control is recommended for improved lumbar fusion outcomes.
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| 5. |
- Diarbakerli, Elias, et al.
(författare)
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Swedish musculoskeletal researchers view on a collaborative network and future research priorities in Swedish healthcare
- 2024
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Ingår i: Musculoskeletal Care. - : John Wiley & Sons. - 1478-2189 .- 1557-0681. ; 22:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Musculoskeletal disorders (MSK) are a global burden causing significant suffering and economic impact. Systematic identification and targeting of research questions of highest interest for stakeholders can aid in improving MSK disorder knowledge and management.Objective: To obtain Swedish MSK researchers' opinions and views on a collaborative Swedish MSK network (SweMSK) and identify future research areas of importance for Swedish MSK research.Methods: A web-based survey was conducted July to September 2021 to collect data from 354 Swedish MSK researchers. The survey focused on the need, objectives, and structure of a SweMSK network and identified prioritised areas for future MSK research.Results: The study included 141 respondents, of which 82 were associate professors or professors. The majority (68%) supported the creation of a new musculoskeletal network. The most supported element was increased collaboration regarding nationwide and multicenter studies. Respondents recommended the creation of a homepage and the establishment of national work groups with different specific interests as the primary elements of a new network.Conclusion: The results demonstrated a need and desire for increased national research collaboration and the creation of a new musculoskeletal network. The high academic experience and active research participation of the respondents suggest the need for MSK disorder knowledge and management improvement in Sweden. Therefore, the SweMSK network may help facilitate effective collaboration and research efforts that can contribute to the advancement of MSK disorder management and care. This study may provide valuable insights for policymakers, clinicians, and researchers to improve MSK disorder care and management in Sweden.
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| 6. |
- Eyles, J.P., et al.
(författare)
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Clinical Outcomes Of Osteoarthritis Management Programs: A Project Of The Oa Trial Bank And Oarsi Joint Effort Initiative Using Individual Participant Data
- 2023
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Ingår i: Osteoarthritis and Cartilage. - : Elsevier. - 1063-4584 .- 1522-9653. ; 31, s. S385-S386
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: People living with osteoarthritis (OA) often do not receive best evidence care. Coordinated OA management programs (OAMPs) have been implemented to address this global evidence-practice gap. An OAMP is defined as a package of care with the following: i) a personalized management plan; ii) with reassessment and progression; iii) using a minimum of 2 core treatments (education, exercise, weight control), and; iv) optional adjunctive therapies. Existing OAMP models differ in treatment mode, intensity, duration, the health professionals delivering care, and the healthcare systems and settings they operate within. Randomized trials (RCTs) and cohort studies assess the outcomes of different OAMPs, however, these models are unlikely to ever be compared in RCTs due to the huge expense and complicated logistics required. Prognosis research provides another method of comparing outcomes of different OAMP models. This study aimed to estimate the pain and self-reported function outcomes (at 12-, 26- and 52-weeks) of people with hip and/or knee OA who participated in international OAMPs. It also aimed to describe the characteristics of OAMP participants.Methods: This study was undertaken by members of the OARSI Joint Effort Initiative (JEI), in collaboration with the OA Trial Bank (Erasmus MC, Netherlands). RCTs and clinical cohorts assessing OAMPs were identified through the JEI membership and literature searches. Eligible studies included data from an ongoing OAMP, in any real-world setting, with participants who were diagnosed with hip or knee OA, and longitudinal measures of patient-reported pain and function. The investigators of eligible studies were invited to complete data delivery agreements with the OA Trial Bank, share individual participant data (IPD), contribute to study design and authorship. Investigators ensured they had local ethics review board approval to contribute IPD to the OA Trial bank. Each dataset was converted to a common format to enable merging into one dataset. The IPD were evaluated to convert pain and function variables to standardized scales as appropriate. Pain scores were converted to a 0-100 point scale (100 worst). Function scores were converted to a 0-100 point scale (100 best). A generalized estimating equations (GEE) model analysis was performed to assess the change in pain and function from baseline across weeks 12, 26, and 52. The model specification was based on an unstructured correlation structure and robust standard errors. Pain and function estimates were adjusted by age, sex and body mass index (BMI). Data analyses were carried out using Stata 15 (StataCorp 2015) and SPSS 17.Results: The investigators of 13 international OAMPs were invited to take part. IPD from 9 OAMPs were delivered: the OA Chronic Care Program, Ramsay Health OA Management Program, Joint Health Program, University of Wisconsin Health Knee and Hip Comprehensive Non-Surgical OA Management Clinic, Improved Management of Patients With Hip and Knee OA in Primary Health Care, Joint Academy, Amsterdam OA cohort, Management of OA In Consultations, and Collaborative model of care between Orthopaedics and allied healthcare professionals in knee OA. The characteristics of the OAMPs are summarised in table 1. The OAMPs were conducted in-person except for the Joint Academy that was implemented as an online OAMP. Individual participant data from 9819 participants were analyzed. The cohort studies were missing large amounts of data, as expected in clinical practice. The characteristics of OAMP participants are summarised in Table 2. The majority of OAMP participants reported the knee as their index joint, their mean age ranged between 62- 67 years, 58-74% were female, 25-48% were working and mean BMI indicated they were overweight at baseline. Pain was most commonly assessed using a Numeric Rating Scale or validated questionnaires e.g. the Knee Injury and OA Outcome Scale (KOOS). Function was mostly assessed using validated questionnaires such as the KOOS. The pain and fuction measured in the original datasets are reported in Table 1. The changes in pain and function of the OAMP participants from baseline across weeks 12, 26, and 52 are summarised in Table 3. There were reductions in pain scores and improvements in function scores seen across all programs at the majority of timepoints.Conclusions: We established the first data bank of IPD from different international OAMPs. Analysis of the IPD demonstrated modest improvements in pain and function across the programs at all timepoints. The most rapid improvements were made by week-12, however, these gains were maintained at week-52. In future work this project will use IPD meta-analysis to identify prognostic factors of people with OA who participate in OAMPs.
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| 7. |
- Charalampidis, Anastasios, et al.
(författare)
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Nighttime Bracing or Exercise in Moderate-Grade Adolescent Idiopathic Scoliosis
- 2024
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Ingår i: JAMA Network Open. - : AMER MEDICAL ASSOC. - 2574-3805. ; 7:1
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Tidskriftsartikel (refereegranskat)abstract
- IMPORTANCE Moderate-grade adolescent idiopathic scoliosis (AIS) may be treated with full-timebracing. For patients who reject full-time bracing, the effects of alternative, conservativeinterventions are unknown.OBJECTIVE To determine whether self-mediated physical activity combined with either nighttimebracing (NB) or scoliosis-specific exercise (SSE) is superior to a control of physical activity alone (PA)in preventing Cobb angle progression in moderate-grade AIS.DESIGN, SETTING, AND PARTICIPANTS The Conservative Treatment for Adolescent IdiopathicScoliosis (CONTRAIS) randomized clinical trial was conducted from January 10, 2013, throughOctober 23, 2018, in 6 public hospitals across Sweden. Male and female children and adolescentsaged 9 to 17 years with an AIS primary curve Cobb angle of 25° to 40°, apex T7 or caudal, and skeletalimmaturity based on estimated remaining growth of at least 1 year were included in the study. Datesof analysis were from October 25, 2021, to January 28, 2023.INTERVENTIONS Interventions included self-mediated physical activity in combination with eitherNB or SSE or PA (control). Patients with treatment failure were given the option to transition to afull-time brace until skeletal maturity.MAIN OUTCOMES AND MEASURES The primary outcome was curve progression of 6° or less(treatment success) or curve progression of more than 6° (treatment failure) seen on 2 consecutiveposteroanterior standing radiographs compared with the inclusion radiograph before skeletalmaturity. A secondary outcome of curve progression was the number of patients undergoing surgeryup until 2 years after the primary outcome.RESULTS The CONTRAIS study included 135 patients (45 in each of the 3 groups) with a mean (SD)age of 12.7 (1.4) years; 111 (82%) were female. Treatment success was seen in 34 of 45 patients (76%)in the NB group and in 24 of 45 patients (53%) in the PA group (odds ratio [OR], 2.7; 95% CI, 1.1-6.6).The number needed to treat to prevent curve progression with NB was 4.5 (95% CI, 2.4-33.5).Treatment success occurred in 26 of 45 patients (58%) in the SSE group (OR for SE vs PA, 1.2; 95% CI,0.5-2.8). Up to 2 years after the primary outcome time point, 9 patients in each of the 3 groupsunderwent surgery.CONCLUSIONS AND RELEVANCE In this randomized clinical trial, treatment with NB preventedcurve progression of more than 6° to a significantly higher extent than did PA, while SSE did not; inaddition, allowing transition to full-time bracing after treatment failure resulted in similar surgicalfrequencies independent of initial treatment. These results suggest that NB may be an effectivealternative intervention in patients rejecting full-time bracing.
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