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Assessment and Management of Pain, Alignment, Strength and Stability (PASS) in Patellofemoral Pain and Low Back Pain

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Assessment and Management of Pain, Alignment, Strength and Stability (PASS) in Patellofemoral Pain and Low Back Pain

Abstract

Clinical assessment and management of musculoskeletal conditions of different joints may be broken down into considerations of Pain, Alignment, Strength and Stability (PASS). In recent years these factors have allowed a systematic approach and has enabled the development in our understanding of clinical subgroups, which enable targeted or stratified care. This paper considers the use of the PASS concept to determine the most appropriate treatment and interventions, specifically when considering treatment of two common musculoskeletal conditions, patellofemoral pain and low back pain.
ISSN 1803-4330 • ročník 11 / 2 • listopad 2018 8
ročník 11 / 2 • listopad 2018
ISSN 1803-4330
recenzovaný časopis pro nelékařské zdravotnické obory
Assessment and Management of Pain, Alignment, Strength and Stability (PASS)
inPatellofemoral Pain and Low Back Pain
Alex Mbuli1,2, Ambreen Chohan1, Jessica Janssen1, Olivia Greenhalgh1, Lauren Haworth1, Hannah Shore1,
Mairi Olivier1, Hazel Roddam1, Louise Anne Connell1, Jim Richards1
1Allied Health Research unit, University of Central Lancashire, UK
2Sport, Exercise & Health Sciences, Edinburgh Napier University, UK
ABSTRACT
Clinical assessment and management of musculoskeletal conditions of different joints may be broken down
into considerations of Pain, Alignment, Strength and Stability (PASS). In recent years these factors have allowed
asystematic approach and has enabled the development in our understanding of clinical subgroups, which en-
able targeted or stratified care. This paper considers the use of the PASS concept to determine the most appro-
priate treatment and interventions, specifically when considering treatment of two common musculoskeletal
conditions, patellofemoral pain and low back pain.
INTRODUCTION
The clinical assessment and management of muscu-
loskeletal conditions of different joints may be bro-
ken down into considerations of Pain, Alignment,
Strength and Stability (PASS), which may be used
to assess treatment and interventions. This provides
a framework that encourages the practitioner and
researcher to address these four factors when con-
sidering a treatment for aspecific pathology. Each
of the factors outlined below need to be considered,
as these help to identify the specific needs of the pa-
tient, which can be used to target specific aspects and
outcomes of the condition and provides a patient
centred approach.
Pain may result from an injury or an ongoing con-
dition such as mechanical low back pain (MLBP) or
patellofemoral pain (PFP), this can result in areduc-
tion in activity and can affect an individuals quality
of life. According to the Health and Safety Execu-
tive’s (HSE) annual statistics, in the United Kingdom
2.2 million working days are lost as aresult of back
disorders and 1.7 million as aresult of work relat-
ed lower limb disorders (HSE 2018). By addressing
this aspect of PASS, the impact of pain may be min-
imised through aclinically significant reduction in
pain. This in turn may lead to patients moving with
greater ease and being able to return to activities of
daily living or sports. When considering alignment
we often consider malalignment, or the lack of con-
trol of alignment of specific joints within the body.
This can have devastating results on an individual’s
participation in activities of daily living. By observ-
ing deficits in movement patterns of joints and sur-
rounding structures, it may be possible to use specif-
ic interventions to target and correct such deficits;
these in turn will then have apositive impact on pain
and wellbeing. Richards et al (2005) showed that by
using a targeted intervention such as knee bracing
in osteoarthritis patients improvements in function,
loading and propulsive forces can be made. Strength
is also akey aspect that allows practitioners to de-
termine deficits in force production. By strengthen-
ing muscular structures through increased physical
activity and targeted exercise regimes a reduction
has been seen in pain and disability that has been
associated with knee arthritis (Wearing et al 2006).
Weakness in a structure could lead to compensa-
tions, which could negatively impact or even cause
injury at another site. However, strength should not
just be considered in terms of maximal output, but
should be put in context as to the optimal force for
the structures being assessed, as over strengthening
could lead to amuscle imbalance or joint overload.
Such an imbalance in strength can result in deficits
in musculoskeletal stability, however these may not
be just mechanical, and proprioceptive or control
deficits may also be responsible.
The Medical Research Council (MRC) guidelines
for complex interventions (2019) state that research-
ers should be clear about the aim when developing
a study. By framing the research question around
DOI: 10.5507/pol.2018.005
ISSN 1803-4330 • ročník 11 / 2 • listopad 2018 9
the elements of PASS, the researcher or practition-
er can ensure that they are establishing the specific
area, or areas of acondition, which they are trying
to address. The use of the PASS framework allows
researchers to consider the implementation of their
findings. The MRC guidelines (2019) asks whether
the findings of astudy can be widely implemented if
the results are favourable. By addressing the factors
outlined in PASS, the route to implementation can
be mapped, as this addresses specific functional defi-
cits, which in turn can be mapped to specific inter-
ventions strategies. In addition, the MRC guidelines
(2019) propose that the results be accessible to de-
cision-makers, which includes patients, who are key
to the decision making process. Using PASS, patients
should be able to better comprehend what the treat-
ments or interventions are trying to target.
THE USE OF PASS IN THE MANAGEMENT
OFLOW BACK PAIN
Eighty percent of adults experience Low Back Pain
(LBP) at some point in their adult life (Kent & Keat-
ing, 2005). LBP is acostly musculoskeletal disorder,
often relating to poor posture and movement habits,
and caused by an imbalance in the supporting struc-
tures of the spine (Comerford and Mottram, 2001).
LBP patients often struggle to move freely, and ac-
tivities of daily living, sleep and work are often hin-
dered as aresult of pain (Jensen et al, 2000; Moren et
al, 2002; Wang et al, 2004; Manchikanti et al, 2014).
Highly significant relationships have been shown in
the literature between LBP and quality of sleep, with
reports of 55% increase in restless/light sleep follow-
ing the onset of pain (Marin et al, 2006). However,
LBP is abroad term often used to cover amultitude
of chronic and acute, muscular, mechanical and neu-
rological disorders. It has been shown that a large
majority (80–90%) of individuals will recover with-
in 12 weeks (Andersson, 1999), however permanent
disability accounts for 5–15% of patients (Liebenson,
1996). This has ahuge potential economic effect on
annual direct healthcare costs, which has previous-
ly been estimated to reach £1632 million in the UK
(Maniadakis and Gray, 2000). Therefore, correct
clinical diagnosis is key to the effective treatment
and rehabilitation. As aresult, anumber of measures
and tools commonly used in clinical practice have
been included within research studies published to
date. These help determine the effectiveness of dif-
ferent interventions in the management of LBP.
Measurement of pain, function and ability
amongst individuals with LBP should include the
use of validated clinical questionnaires to determine
the effectiveness of an intervention or rehabilitation
programme. Examples of functional assessment in-
clude; the Roland Morris Disability Questionnaire,
the Core Outcome Measures Index or the Oswestry
Disability Index for function and quality of activities
of daily living. In addition, assessments of pain fre-
quently reported include; the Numerical Pain Rating
Scale (NPRS) and Short Form McGill Pain Question-
naire 2 (SF-MPQ-2) (Deyo et al, 1998; Fairbank and
Pysent, 2000; Ostello et al, 2008; Salaffi et al, 2004;
Kamper et al, 2010). The NPRS provides an insight
into the subjective severity of pain on anumerical
scale from 0 to 10. The SF-MPQ-2 further investi-
gates the severity of different sub-types of pain (con-
tinuous, intermittent, neurological, and affective) on
anumerical scale similar to the NPRS. Pain related
questionnaires should be used prior to any interven-
tion as abaseline measure, and then again at subse-
quent follow up sessions to monitor any change in
pain. The NPRS has been well researched and aMin-
imal Clinical Important Difference (MCID) of 1.7
points, or a28% change is required to determine that
an intervention is useful amongst chronic LBP pa-
tients. However, the presence of pain alone does not
give enough information to enable atreatment strat-
egy to be determined, current function and activity
levels or limitations should also be considered.
Rehabilitative measures may involve the use of
medical devices, such as lumbar bracing to improve
alignment and associated pain (Weiss and Werk-
mann, 2009). But may also include simple lifestyle
changes such as changing the sleeping surface to
a more supportive mattress (Chohan et al, 2013,
2018), or the introduction of acorrectly fitted and
supportive bra (Chohan et al, 2016), which can
provide important changes in alignment. Postural
assessments and corrective techniques are there-
fore often key to the management of such patients.
Malalignment of the spine undoubtedly has anega-
tive impact on the musculoskeletal system. Posture,
and therefore spinal alignment, is often assessed by
a clinician applying theoretical knowledge through
visual assessment. However, more recent complex
biomechanical methods have been used to quantify
changes in spinal alignment (Preuss and Popovic,
2010), which can be used to determine the efficacy
and effectiveness of different treatment interven-
tions (Chohan et al, 2013).
Strength deficits are also often present in LBP pa-
tients, which are often unilateral, and result in mus-
cle imbalances in the paraspinal muscles (Oddsson
et al, 2003). Compensating for muscle imbalances
over aprolonged period of time can lead to amul-
ISSN 1803-4330 • ročník 11 / 2 • listopad 2018 10
titude of negative health implications (Touche et al,
2008). In patients with LBP, the paraspinal muscles
may exhibit structural changes such as muscle fibre
atrophy, which can result in pain, spinal instabili-
ty, asymmetry and limited range of motion (ROM)
(Arokoski et al, 2004). Correct spinal alignment is
achieved through complex loading patterns on the
passive structures of the spine, including the paraspi-
nal and trunk muscles (Arokoski et al, 2004). Such
activity may be assessed using surface electromy-
ography (EMG), which allows aquantification of the
muscle activity around the spine during simple ROM
tasks (Oddsson et al, 2003). Any imbalance in the
muscle activity may be associated with an imbalance
in strength which may be directly associated with
pain (Oddsson et al, 2003).
THE USE OF PASS IN THE MANAGEMENT
OF PATELLOFEMORAL PAIN
Patellofemoral pain (PFP) is achronic musculoskele-
tal condition usually presented by persistent pain in,
or around, the patella (Callaghan & Selfe, 2007). One
in five people in the general population experiences
PFP (Smith et al 2018). However, long term progno-
sis with current multimodal therapy for PFP is poor
(Lankhorst et al 2016). A recent paper by Selfe et al
(2016) explored the use of specific assessments to de-
termine subgroups within the PFP population. These
consisted of “weak and pronated” (39%), “weak and
tighter” (39%), and “strong” (22%). These subgroups
raise anumber of important questions about possi-
ble treatment strategies. Namely, the use of strength-
ening protocols in the weak groups, the use of foot
orthoses to correct alignment in the weak and pro-
nated group, and the consideration that patellofemo-
ral overload and/or instability may be relevant in the
strong group.
All people with PFP present with pain, which can
be measured by using the NPRS, VAS, or the new-
ly developed KOOS_PF (Crossley et al 2017), to set
abaseline measurement. Evaluation can happen over
time to determine if pain is reduced. The minimal
clinical important difference (MCID) for the NPRS
and the VAS have been found to be 1 point or 20 mm
in people with chronic musculoskeletal (MSK) pain
(Salaffi et al 2004). This means that when apatient
shows achange which exceeds this threshold there
is ameaningful clinical difference for this patient. A
MCID for the KOOS-PF has yet to be determined.
However, as with LBP, the presence of pain alone
does not give enough information to enable atreat-
ment strategy to be determined.
People in the “weak and pronated” subgroup
present with apoor foot position, which in turn can
lead to malalignment of the tibia and patella (Curren
2017). The Foot Posture Index (FPI) (Redmond et al
1998) is acomprehensive assessment tool to identi-
fy foot type. The FPI consists of six measurements
that provide acombined score of -12 to 12. A score
over +6 indicates that apatient has apronated foot
(Redmond et al 1998). Furthermore, aFPI score of
+6 was the threshold found for inclusion in the weak
and pronated foot group by Selfe et al (2016). The
alignment of the foot can be corrected using foot or-
thoses, which in turn can correct the malalignment
of the tibia and patella (Curren 2017).
Individuals with PFP, specifically those within the
weak subgroups, most often present with significant
differences in the quadriceps femoris muscle (QFM)
compared to the healthy population. Differences in
the morphology and architecture of the vastus me-
dialis (VMO), particularly in the more distal aspect
of the muscle (Pattyn et al 2009) result in under-de-
velopment and reduced muscle strength compared
to healthy individuals (Van Tiggelen et al 2009). In
addition, during voluntary muscle contraction, it has
been accepted that individuals with PFP present with
a delayed muscle activation of VMO compared to
vastus lateralis (VL). QFM strengthening, as part of
arehabilitation program for PFP patients, has been
supported by Giles et al (2013), as it has been iden-
tified that QFM atrophy is prevalent amongst PFP
patients within the weak subgroups. Neuromuscular
electrical stimulation (NMES), has also been shown
to improve function and reduces pain amongst Os-
teoarthritis (OA) patients by targeting the injured/
affected structures within the QFM (de Oliveira
Melo et al 2014). In combination with this, volun-
tary activation of the QFM is improved, which is an
important step within muscle recovery and OA man-
agement (Elboim-Gabyzon et al 2013).
Amongst both PFP and OA patients, joint stress-
es are associated to chondral and osseous chang-
es (Wyndow et al 2016). Through the introduction
of NMES, with an aim to improve muscle strength
within aPFP rehabilitation program, the functional
capacity of QFM may be increased whilst also man-
aging pain, similar to that prescribed for OA patients
(Dos Santos et al 2013). Dos Santos et al identified
that both muscle rebalance and pain relief may be
achieved by combining NMES and resistance exer-
cises within an individual PFP patients treatment
plan. Therefore, clinicians may be advised to consid-
er the introduction of NMES and resistance exercises
ISSN 1803-4330 • ročník 11 / 2 • listopad 2018 11
for the treatment for PFP patients within the weak
subgroups.
When considering PFP, knee stability and the as-
sociated interventions, it is important to look at not
just the sagittal plane knee mechanics, but to also
consider the movement in the coronal and transverse
planes. The tests used to assess movement need to
challenge the dynamic control of the patella, howev-
er activities such as level walking do not offer asuffi-
cient challenge (Selfe et al 2007). In addition, Selfe et
al described how adynamic movement such as astep
down can give asufficient challenge to the stability
of the knee. Therefore, these dynamic control tests
allow for the assessment of stability in not only the
sagittal plane but also the coronal and transverse
planes. With the knee having six degrees of freedom
of motion, it is important not to ignore motion in the
other planes as highlighted by Kowalk et al (1996).
Kowalk et al showed that the knee abduction–adduc-
tion moment should not be ignored when assessing
knee stability during stair climbing, even though this
is not the primary plane in which motion occurs.
In addition, PFP patients who reported the greatest
pain have been shown to have the greatest instability
(Selfe et al 2011). Implementing the correct interven-
tion to address this issue of stability is critical. Stud-
ies have shown that there are arange of techniques
and devices that can offer incremental increases in
stability through proprioception and neuromuscular
control (Selfe et al 2011; Petersen et al 2014). Howev-
er, it remains unclear whether such effects are pres-
ent in all of the subgroups identified by Selfe et al
(2016).
HUMAN FACTORS ASSOCIATED WITH PASS
Another aspect that should be considered are the
human factors, the ways in which aperson will in-
teract with the systems around them. This has been
acknowledged as an increasingly as acritical part of
any product or service design. Indeed, for the first
time in 2016, the UK Medicines and Healthcare Reg-
ulatory Products Agency (MHRA) released the first
draft guidance on human factors aspects of design
for medical devices (MHRA Human Factors guid-
ance, 2018). The key principles of human factors are
all focused around reducing human error by making
asystem as simple to use as possible, both cognitive-
ly and physically. Is the system easy to use? Where
physical products are involved, are they ergonomi-
cally sound and comfortable to use? These principles
apply for both the patient, and the therapist (Health
and Safety Executive, 2018). Therefore, when con-
sidering targeted interventions, the PASS framework
fits into this by providing therapists with a struc-
tured programme to work with, reducing reliance on
memory and simplifying the process. For patients, it
provides aclear framework for them to understand,
aiding acceptance of any intervention.
CONCLUSION
The clinical assessment and management of muscu-
loskeletal conditions of different joints may be broken
down into considerations of Pain, Alignment, Strength
and Stability (PASS). This provides therapists with
astructured programme to work with, reducing reli-
ance on memory and simplifying the process; whilst
for patients, it provides aclear framework for them
to understand, aiding acceptance of any intervention.
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CORRESPONDENCE ADDRESS OF MAIN
AUTHOR
Alex Mbuli
Sport, Exercise & Health Sciences
Edinburgh Napier University
Edinburgh, UK
+447988770838
email: a.mbuli@napier.ac.uk
Přijato krecenzi: 25. 10. 2018
Přijato do tisku: 12. 12. 2018
Research
Full-text available
This report highlights the successes of the Allied Health Research Unit in 2018-2019 including current projects and publications, through to future developments.
Article
Full-text available
Background Patellofemoral pain is considered one of the most common forms of knee pain, affecting adults, adolescents, and physically active populations. Inconsistencies in reported incidence and prevalence exist and in relation to the allocation of healthcare and research funding, there is a clear need to accurately understand the epidemiology of patellofemoral pain. Methods An electronic database search was conducted, as well as grey literature databases, from inception to June 2017. Two authors independently selected studies, extracted data and appraised methodological quality. If heterogeneous, data were analysed descriptively. Where studies were homogeneous, data were pooled through a meta-analysis. Results 23 studies were included. Annual prevalence for patellofemoral pain in the general population was reported as 22.7%, and adolescents as 28.9%. Incidence rates in military recruits ranged from 9.7–571.4/1,000 person-years, amateur runners in the general population at 1080.5/1,000 person-years and adolescents amateur athletes 5.1%–14.9% over 1 season. One study reported point prevalence within military populations as 13.5%. The pooled estimate for point prevalence in adolescents was 7.2% (95% Confidence Interval: 6.3%–8.3%), and in female only adolescent athletes was 22.7% (95% Confidence Interval 17.4%–28.0%). Conclusion This review demonstrates high incidence and prevalence levels for patellofemoral pain. Within the context of this, and poor long term prognosis and high disability levels, PFP should be an urgent research priority. PROSPERO registration CRD42016038870
Conference Paper
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Background A third of our lifetime is spent in bed [1], so to achieve improved quality of sleep it is vital to establish optimal sleeping conditions. A sleep system’s main function is to support the body in such a way that the muscles and intervertebral discs are able to recover from an almost continuous load throughout the day. This allows the pressure to be relieved from the intervertebral discs and surrounding musculature, therefore initiating recovery, rehydration and regeneration of elasticity within soft tissues [2-3]. Failure to achieve a state of recovery can lead to the onset of Lower Back Pain (LBP), which is said to have effected 2/3 adults within the UK, and as many as 2.5 million people on a daily basis. There are a variety of mechanisms said to reduce LBP and subsequently improve the quality of sleep including improved spinal alignment, and the reduction of pressure at main contact areas between the body and the mattress [4-6]. Whilst varying comfort layers and mattress firmness can help to address these mechanisms of LBP, mattress zoning is one of the latest developments in pocket sprung mattress design aiming to improving sleep quality and reducing LBP, and thus this study explored the biomechanical differences between a zoned (Z) and non-zoned (NZ) mattress on humans. Methods Twelve healthy participants (aged 35.9±13.1 years) were recruited and screened using the Red flags screening questionnaire [7]. Ten QualisysTM Oqus7 cameras recorded movement of the spine in 6 degrees of freedom using a multisegment spine model [8] during side lying. Z and NZ 1000-count pocket sprung mattresses, topped with a minimal comfort layer were used. Additional subjective measures of Mattress comfort and firmness taken, whilst pressure distribution was measured at the hip and shoulder (Tekscan, MA, USA). Results A significantly higher peak hip pressure (2.92kPa) was noted for the Z mattress compared to the non-zoned (2.63kPa; p=0.004). No significant differences in peak pressure at the shoulder were noted between the two mattresses. There was no significance relating to perceived mattress firmness or comfort (p=0.524 and p=0.537 correspondingly). Spinal posture was measured in terms of how far posture varied from a neutral position. Within the sagittal plane there were significant differences between the Z and NZ mattresses at the UL-LL region (p=0.046) with the Z mattress deviating the least. Similarly, within the coronal plane the UT-MT (p=0.038) and LT-UL (p=0.024) posture demonstrated statistically significant improvements. The Z mattress demonstrated less rotation within the LL-PEL segment of the spine (p=0.012), however it displayed significantly poorer results within the LT-UL and UL-LL segments (p=0.026 and p=0.016 respectively). Discussion There is evidence to suggest that whilst a zoned mattress does not disperse pressure as effectively at the hip, it is in fact more supportive to compensate as it reduces “hammocking” and improves overall spinal alignment. The zoned mattress outperformed the non-zoned mattress in key areas around the lower lumbar to pelvic region suggesting that it may help to reduce torsional strains, potentially helping individuals with LBP. It is evident from this data that a multi-factoral approach is beneficial in understanding our interaction with sleep surfaces.
Article
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The patellofemoral (PF) joint is the knee compartment most commonly affected by osteoarthritis (OA). Even mild PF OA is associated with considerable pain and functional limitations. Despite its prevalence and impact, little is understood of the etiology or structural and functional features of PF OA. The clinical symptoms of PF OA, such as anterior knee pain during stair ambulation and squatting, share many similarities with PF pain in adolescents and young adults. PF joint OA is most commonly diagnosed in people aged >40 years, many of whom report a history of PF pain. As such, there is growing evidence that PF pain and PF OA form a continuum of disease. This review explores the possible relationship between the presence of PF pain and the development of PF OA. We review the evidence for altered neuromotor control and biomechanical factors that may be associated with altered PF loading in people with PF pain and PF OA. In doing so, we highlight similarities and differences that may evolve along the continuum. By improving our understanding of the neuromotor and biomechanical links between PF pain and PF OA, we may highlight potential targets for new rehabilitation strategies.
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Background Patellofemoral pain and osteoarthritis are prevalent and associated with substantial pain and functional impairments. Patient-reported outcome measures (PROMs) are recommended for research and clinical use, but no PROMs are specific for patellofemoral osteoarthritis, and existing PROMs for patellofemoral pain have methodological limitations. This study aimed to develop a new subscale of the Knee injury and Osteoarthritis Outcome Score for patellofemoral pain and osteoarthritis (KOOS-PF), and evaluate its measurement properties. Methods Items were generated using input from 50 patients with patellofemoral pain and/or osteoarthritis and 14 health and medical clinicians. Item reduction was performed using data from patellofemoral cohorts (n=138). We used the COnsesus-based Standards for the selection of health Measurements INstruments guidelines to evaluate reliability, validity, responsiveness and interpretability of the final version of KOOS-PF and other KOOS subscales. Results From an initial 80 generated items, the final subscale included 11 items. KOOS-PF items loaded predominantly on one factor, pain during activities that load the patellofemoral joint. KOOS-PF had good internal consistency (Cronbach’s α 0.86) and adequate test–retest reliability (intraclass correlation coefficient 0.86). Hypothesis testing supported convergent, divergent and known-groups validity. Responsiveness was confirmed, with KOOS-PF demonstrating a moderate correlation with Global Rating of Change scores (r 0.52) and large effect size (Cohen’s d 0.89). Minimal detectable change was 2.3 (groups) and 16 (individuals), while minimal important change was 16.4. There were no floor or ceiling effects. Conclusions The 11-item KOOS-PF, developed in consultation with patients and clinicians, demonstrated adequate measurement properties, and is recommended for clinical and research use in patients with patellofemoral pain and osteoarthritis.
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Background: Larger breasted women are at higher risk of wearing ill-fitting breast-support garments. Failure to support breasts during everyday activity can lead to physiological conditions including back and breast pain. This study aimed to identify initial and short-term (4 weeks) biomechanical change and patient reported outcome measures (PROMS) in larger breasted women with non-specific back pain (NSBP) when wearing different breast-support garments. Methods & Results: 20 females (Age: 32.1±9.4 years; Bra sizes: 36DD-32K) with NSBP were recruited using modified red flags screening. Participants were tested initially in their usual bra, followed by the professionally-fitted and Optifit bras, in randomised order. Pre/post assessments comprised an established bra-fit assessment, body chart analysis, frequency of wear and pain, continuous-pain intensity (SF-MPQ-2), back stiffness and discomfort, neck disability and thoracic posture in standing using 3D-movement analysis. 100% of Usual and 90% of professionally-fitted bras failed the bra-fit assessment, compared to 5% with the Optifit. Though worn the least on average, a short-term intervention with the Optifit bra resulted in significant reductions in reported thoracic pain, clinically important reductions in neck disability, back pain frequency, continuous-pain intensity, stiffness and discomfort compared to the other bras. The Optifit and professionally-fitted bras significantly reduced reported lumbosacral pain compare to the usual bra. There was no initial change in thoracic posture with the Optifit bra however, significant improvements in flexion-extension posture were seen post-intervention. Conclusions: Following a short-term intervention, larger breasted women with NSBP appear to show some clinically important improvements. Provision of correctly fitting breast-support garments may contribute to better clinical management of NSBP in these women.
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Background: Current multimodal approaches for the management of non-specific patellofemoral pain are not optimal, however, targeted intervention for subgroups could improve patient outcomes. This study explores whether subgrouping of non-specific patellofemoral pain patients, using a series of low cost simple clinical tests, is possible. Method: The exclusivity and clinical importance of potential subgroups was assessed by applying à priori test thresholds (1 SD) from seven clinical tests in a sample of adult patients with non-specific patellofemoral pain. Hierarchical clustering and latent profile analysis, were used to gain additional insights into subgroups using data from the same clinical tests. Results: 130 participants were recruited, 127 had complete data: 84 (66%) female, mean age 26 years (SD 5.7) and mean body mass index 25.4 (SD 5.83), median (IQR) time between onset of pain and assessment was 24 (7-60) months. Potential subgroups defined by the à priori test thresholds were not mutually exclusive and patients frequently fell into multiple subgroups. Using hierarchical clustering and latent profile analysis three subgroups were identified using 6 of the 7 clinical tests. These subgroups were given the following nomenclature: (1) 'strong', (2) 'weak and tighter' and (3) 'weak and pronated foot'. Conclusions: We conclude that three subgroups of patellofemoral patients may exist based on the results of six clinical tests which are feasible to perform in routine clinical practice. Further research is needed to validate these findings in other data sets and, if supported by external validation, to see if targeted interventions for these subgroups improve patient outcomes.
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Background Patellofemoral pain (PFP) has traditionally been viewed as self-limiting, but recent studies show that a large proportion of patients report chronic knee pain at long-term follow-up. We identified those patients with an unfavourable recovery (‘moderate improvement’ to ‘worse than ever’ measured on a Likert scale) and examined whether there is an association between PFP and osteoarthritis (OA) at 5–8-year follow-up. Methods Long-term follow-up data were derived from 2 randomised controlled trials (n=179, n=131). Patient-reported measures were obtained at baseline. Pain severity (100 mm visual analogue scale (VAS)), function (Anterior Knee Pain Scale (AKPS)) and self-reported recovery were measured 5–8 years later, along with knee radiographs. Multivariate backward stepwise linear regression analyses were used to evaluate the prognostic ability of baseline pain duration, pain VAS and AKPS on outcomes of pain VAS and AKPS at 5–8 years. Results 60 (19.3%) participants completed the questionnaires at 5–8-year follow-up (45 women, mean age at baseline 26 years) and 50 underwent knee radiographs. No differences were observed between responders and non-responders regarding baseline demographics, and 3-month and 12-month pain severity and recovery. 34 (57%) reported unfavourable recovery at 5–8 years. 48 out of 50 participants (98%) had no signs of radiographic knee OA. Multivariate models revealed that baseline PFP duration (>12 months; R²=0.22) and lower AKPS (R²=0.196) were significant predictors of poor prognosis at 5–8 years on measures of worst pain VAS and AKPS, respectively. Summary and conclusion More than half of participants with PFP reported an unfavourable recovery 5–8 years after recruitment, but did not have radiographic knee OA. Longer PFP duration and worse AKPS score at baseline predict poor PFP prognosis. Education of health practitioners and the general public will provide patients with more realistic expectations regarding prognosis.
Article
Study Design. An international group of back pain researchers considered recommendations for standardized measures in clinical outcomes research in patients with back pain. Objectives. To promote more standardization of outcome measurement in clinical trials and other types of outcomes research, including meta‐analyses, cost‐effectiveness analyses, and multicenter studies. Summary of Background Data. Better standardization of outcome measurement would facilitate comparison of results among studies, and more complete reporting of relevant outcomes. Because back pain is rarely fatal or completely cured, outcome assessment is complex and involves multiple dimensions. These include symptoms, function, general well‐being, work disability, and satisfaction with care. Methods. The panel considered several factors in recommending a standard battery of outcome measures. These included reliability, validity, responsiveness, and practicality of the measures. In addition, compatibility with widely used and promoted batteries such as the American Academy of Orthopaedic Surgeons Lumbar Cluster were considered to minimize the need for changes when these instruments are used. Results. First, a six‐item set was proposed, which is sufficiently brief that it could be used in routine care settings for quality improvement and for research purposes. An expanded outcome set, which would provide more precise measurement for research purposes, includes measures of severity and frequency of symptoms, either the Roland or the Oswestry Disability Scale, either the SF‐12 or the EuroQol measure of general health status, a question about satisfaction with symptoms, three types of "disability days," and an optional single item on overall satisfaction with medical care. Conclusion. Standardized measurement of outcomes would facilitate scientific advances in clinical care. A short, 6‐item questionnaire and a somewhat expanded, more precise battery of questionnaires can be recommended. Although many considerations support such recommendations, more data on responsiveness and the minimally important change in scores are needed for most of the instruments.
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Objective Low back pain affects many individuals. It has profound effects on well-being and is often the cause of significant physical and psychological health impairments. Low back pain also affects work performance and social responsibilities, such as family life, and is increasingly a major factor in escalating health-care costs. A global review of the prevalence of low back pain in the adult general population has shown its point prevalence to be approximately 12%, with a one-month prevalence of 23%, a one-year prevalence of 38%, and a lifetime prevalence of approximately 40%. Furthermore, as the population ages over the coming decades, the number of individuals with low back pain is likely to increase substantially. This comprehensive review is undertaken to assess the increasing prevalence of low back pain and the influence of comorbid factors, along with escalating costs.Materials and MethodsA narrative review with literature assessment.ResultsIn the USA, low back pain and related costs are escalating. Based on the available literature, it appears that the prevalence of low back pain continues to increase, along with numerous modalities and their application in managing low back pain. Comorbid factors with psychological disorders and multiple medical problems, including obesity, smoking, lack of exercise, increasing age, and lifestyle factors, are considered as risk factors for low back pain.Conclusion Although it has been alleged that low back pain resolves in approximately 80% to 90% of patients in about six weeks, irrespective of the administration or type of treatment, with only 5% to 10% of patients developing persistent back pain, this concept has been frequently questioned as the condition tends to relapse and most patients experience multiple episodes years after the initial attack.