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- Cross-cultural adaptation and psychometric properties of the european portuguese version of the Global Perceived Effect Scale in patients with chronic low back painPublication . Freitas, Petra; Pires, Diogo; Nunes, Carla; Cruz, EduardoPurpose: To cross-culturally adapt the Global Perceived Effect Scale (GPES) into Portuguese and investigate its psychometric properties in patients with chronic low back pain. Methods: Cross-cultural adaptation was carried out according to published guidelines. Along with measures for pain and disability, GPES was administered at baseline, 48-h later and post-intervention. To estimate test-retest reliability, the intraclass correlation coefficient was used. The validity was examined through the correlation between the GPES and the Patient Global Improvement Change Scale and the contribution of baseline status to GPES scores. Responsiveness was assessed by analyzing hypotheses regarding areas under the curve and correlations with changes in other measures. Results: The test-retest reliability, the convergent validity and the contribution of the baseline status to GPES scores were demonstrated. The EPES correlated strongly with global perception of change (r=0.677), and moderately with pain and disability changes (r=0.457 and r=0.452, respectively). Areas under the curve values of 0.71(95% CI = 0.607–0.825) and 0.83 (95% CI = 0.749–922) were found. Conclusion: The GPES demonstrated adequate psychometric properties. This study’s findings supported its use in clinical and research studies with patients with chronic low back pain.
- Tailoring pain neuroscience education and exercise programme for people with fibromyalgia who also have cognitive deficits: a case seriesPublication . Pires, Diogo; Costa, Daniela; Martins, Isabel; Cruz, EduardoPurpose: The purpose of this case series was to describe the outcomes of a tailored pain neuroscience education (PNE) and individualised exercise programme for people with fibromyalgia (FM) who also have cognitive deficits. Materials and methods: Nine FM patients with memory and concentration problems underwent a sixweek programme consisting of six PNE sessions followed by six sessions of individualised exercise. Participants were assessed at the baseline, 3 and 6 weeks, and at 3 and 6 months follow-ups. Outcomes measures included the Tampa Scale of Kinesiophobia (TSK), the Pain Catastrophizing Scale (PCS), the Numerical Pain Rating Scale (NPRS), the Fibromyalgia Impact Questionnaire-Revised (FIQ-R) and the Patient Global Improvement of Change Scale (PGIC). Results: At six weeks, all patients decreased their scores on the TSK, PCS, NPRS and FIQ-R and reported a moderate to considerable improvement in their perception of overall change. At the six-month follow- up, improvements in pain intensity, pain catastrophizing, kinesiophobia and perception of overall change, appeared clinically meaningful for the majority of the participants. Conclusions: This study’s findings demonstrate an example of how cognitive characteristics can be considered in the intervention of FM patients in order to optimise their results and encourage the need for a further randomised control trial.
- Beyond pain and disability: an explanatory mixed methods study exploring outcomes after physiotherapy intervention in patients with chronic low back painPublication . Pires, Diogo; Cruz, Eduardo; Costa, Daniela; Nunes, CarlaPurpose: The primary aim of this study was to explore relevant outcome domains for patients with chronic low back pain (CLBP) undergoing physiotherapy. A secondary aim was to examine potential discrepancies between meaningful changes in pain and disability and the global perception of improvement. Methods: An explanatory mixed methods design was employed. Twenty-two patients with CLBP completed self-reported measures before and after a physiotherapy programme. After the intervention, three focus groups were conducted with patients who perceived an overall improvement. Discussions were recorded, transcribed and analysed using thematic analysis. Results: Quantitative analysis showed an inconsistent relationship between changes in pain and disability measures and global improvements as perceived by patients. Two main themes emerged from the thematic analysis: “pain relief” (subthemes: reducing pain intensity and other symptoms; reducing medication intake; improving sleep quality) and “gaining control over the LBP condition” (subthemes: ability to selfmanage; return to function; and sense of well-being and normality). Conclusion: Patients with CLBP perceived multiple outcomes from physiotherapy treatment that cover the domains of global, physical, mental and social health. These study findings suggest that the targets of measurement for physiotherapy need to be expanded in order to reflect outcome domains valued by patients.
- Minimum important change values for pain and disability: which is the best to identify a meaningful response in patients with chronic nonspecific low back pain?Publication . Pires, Diogo; Cruz, Eduardo; Canhão, Helena; Nunes, CarlaPurpose: To examine the association between different minimum important change (MIC) values for pain and disability and a successful response in global perception of improvement in patients with chronic nonspecific low back pain (CNLBP). Methods: A prospective cohort study was conducted. At baseline, all participants completed a sociodemographic and clinical questionnaire, the Numeric Pain Rating Scale and the Quebec Back Pain Disability Scale (QBPDS). After a physiotherapy program, the Global Perceived Effect Scale (GPES) was completed together with pain and disability measures. The association of the different literature MIC values for pain and disability with a successful response on the GPES was analyzed using logistic regression models. The discrimination power, sensitivity, specificity and predictive values were computed. Results: A total of 183 patients with CNLBP participated in this study. A reduction of 30% on the QBPDS (OR = 7.8; area under the curve = 0.73; sensitivity = 0.72; specificity = 0.76) most accurately identified patients who perceived a global improvement on the GPES. Composite criteria using both pain and disability MIC values presented high odds ratios and specificity values, but failed to identify patients who perceived a meaningful improvement. Conclusion: A 30% reduction on the QBPDS is recommended to identify patients with CNLBP who achieve a clinical improvement with physiotherapy treatment.
- The role of pain and disability changes after physiotherapy treatment on global perception of improvement in patients with chronic low back painPublication . Pires, Diogo; Cruz, Eduardo; Canhão, Helena; Nunes, CarlaBackground: The effectiveness of physiotherapy in patients with chronic low back pain is usually measured through changes in pain and disability domains. However, recent research has suggested that these two domains are not sufficient to capture all the physiotherapy benefits when patients’ perspective is considered. Objective: The aim of this study was to investigate the role of pain and disability changes in explaining the global perception of improvement in patients with chronic low back pain undergoing physiotherapy. Design: Prospective cohort study. Methods: The study was conducted on183 patients who were referred to physiotherapy treatment due to low back pain lasting more than 12 weeks. Sociodemographic and clinical characteristics were measured at baseline, together with pain intensity and disability. Eight (post-intervention) and twelve weeks later, global perception of improvement was measured together with pain and disability. The Pearson correlation coefficient and linear regression models were used for analyses. Results: Of the 183 participants included, 144 completed the 12-weeks follow-up. Significant and moderate correlation was found between pain and disability changes and the global perception of improvement after intervention and at the 12-weeks follow-up. Pain and disability changes explained 20.7%–36.3% of the variance in the global perception of improvement. Conclusions: Pain and disability changes are related and contributed to explaining a partial proportion of variance in the global perception of improvement. The findings suggest that these domains are not sufficient to explain and measure all of the benefits of physiotherapy when patients’ global perception of improvement is considered.
- How do physical therapists measure treatment outcomes in adults with chronic low back pain? a systematic reviewPublication . Pires, Diogo; Cruz, Eduardo; Gomes, Luís A; Nunes, CarlaBackground. There is an increasing recognition of the importance of using a conceptual framework covering the full range of relevant health domains and outcome measures addressed by physical therapy modalities in patients with chronic low back pain (CLBP). However, little is known about what outcome domains have been measured and through what measures in physical therapy research. Objective. The purpose of this review was to synthesize outcome domains, instruments, and cutoff values reported in published randomized controlled trials and their compliance with the original Patient-Reported Outcomes Measurement Information System (PROMIS) framework. Data sources. Embase, MEDLINE, Cochrane Library, and Physiotherapy Evidence Database electronic databases were systematically searched from January 2008 to April 2019. Study selection. Randomized controlled trials that compared physical therapy with any other intervention for adults with CLBP were included. Data extraction. Study characteristics, outcome domains, instruments, and cutoff values were extracted by 2 reviewers. The PROMIS framework was used for domain categorization. Data synthesis. One hundred ninety-five studies were included, with 52 outcome domains and 45 cutoff values identified from 182 instruments reported. Only 14 of 195 studies assessed all PROMIS health core areas, whereas the PROMIS physical health core area was assessed in all included studies. Pain intensity and disability were the most frequently used domains. Limitations. Only studies for which full texts were available in English were included. Conclusions. This review identified a poor overlap between the PROMIS framework and outcome domains used to define the effectiveness of physical therapy in adults with CLBP. This finding suggests that other potential benefits resulting from physical therapy modalities are not being measured. Furthermore, a large diversity in the outcome domains and instruments was found.
- A pain neuroscience education program for fibromyalgia patients with cognitive deficits: a case seriesPublication . Pires, Diogo; Costa, Daniela; Martins, Isabel; Cruz, EduardoBackground: The literature has suggested that Pain neurophysiology education (PNE) can have positive effects on pain, disability and maladaptive pain cognitions in fibromyalgia (FM) patients but no significant changes in these variables have been found in response to PNE in FM patients. Reasons for these findings may relate with the design of the PNE programmes, traditionally composed of only 1 or 2 sessions with a wide variety of complex contents, which do not take into account the memory and concentration problems identified in those patients. Purpose: This case series aims to describe the effects of a combined programme of PNE and exercise for FM patients. The PNE was specifically designed for FM patients with cognitive deficits and included 6 sessions of PNE in a face-to-face format complemented with an educational booklet, the discussion of a case study and involvement of family members in treatment sessions. Methods: Nine consecutive patients with a diagnosis of FM and concentration and memory problems (identified by the concentration subscale of the checklist of Individual strength- CIS-20, and a numeric scale to access memory) were included in this case series. All patients underwent in a 6-week programme (first 3 weeks) followed by 6 sessions of individualized exercise (aerobic exercise, motor control training and aquatic exercise). Participants were assessed at the baseline, 3 and 6 weeks, and at 3 and 6 months follow-ups. Outcomes measures included the Numerical Pain Rating Scale, the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale, and the Patient Global Improvement of Change Scale. Results: All 9 participants were women with a median age of 53 years (range: 38e64). Six weeks after the beginning of the intervention, all the patients reported perceived benefits in perception of overall change, and 7 of the 9 patients (78%) demonstrated a clinically meaningful improvement in pain intensity. Of the 9 participants, 8 exhibited reductions in pain catastrophization and 7 in kinesiophobia. However, at the 6 months follow-up, the proportion of patients with a clinically meaningful improvement in pain intensity and in the perception of overall change decreases to 5/9 and 7/9, respectively. Conclusion: This case series suggests that an adjusted programme of PNE followed by individualized exercise could change maladaptive pain cognitions and decrease pain intensity in FM patients. The dilution of the course content for several sessions and the inclusion of additional learning strategies may have been critical for these results. Implications: This study’s results suggest that cognitive characteristics of FM patients should be considered in the design of PNE programmes in order to optimize their results. However, since a cause-effect relationship cannot be deduced from this case series, a randomized controlled trial should be taken into account to evaluate the effectiveness of this programme in FM patients.
- Successful pain relief in chronic low back pain undergoing multimodal physiotherapy are associated with early response to treatmentPublication . Cruz, Eduardo; Fernandes, Rita; Pires, Diogo; Ribeiro, Ana; Caldeira, Carolina; Costa, Daniela; Duarte, Susana; Domingues, Lúcia
- Adaptação cultural e propriedades psicométricas da versão portuguesa da Global Back Recovery Scale em indivíduos com dor lombar crónicaPublication . Pires, Diogo; Cruz, Eduardo; Freitas, Petra
- Individual patient responder analysis of the effectiveness of a pain neuroscience education programme in chronic low back painPublication . Pires, Diogo; Caeiro, Carmen; Cruz, EduardoBackground: Chronic low back pain (CLBP) is a common health problem to which a large number of types of treatments seem to produce similar mean improvement in patient’s symptoms. Individual responder analyses offer the possibility of providing patients and clinicians with supplementary information about the chance of achieving particular degrees of pain relief, which may improve the decision-making process as well as communication with patients. Purpose: To examine the effectiveness of a combined programme of pain neuroscience education and aquatic exercise (EDU+EXE) versus aquatic exercise alone (EXE) in pain intensity in CLBP patients, and to determine the time course of response in pain intensity and the time course of effectiveness for clinically significant improvements. Methods: A single blind randomized trial, was conducted in patients with CLBP lasting >3 months. The EDU+EXE group (n=30) received 2 sessions of pain neuroscience education followed by 12 sessions of a 6-week aquatic exercise programme, whereas the EXE group (n=32) received 12 sessions of the aquatic exercise programme alone. Patients were assessed at baseline, 3 and 6 weeks after the beginning of the aquatic exercise programme and then at a 12 weeks follow-up. The primary outcome was pain intensity (Visual Analogue Scale). Clinically significant treatment response was defined as a pain relief over baseline of >50%. Results: Analysis using mixed-model ANOVA revealed a significant treatment condition interaction on pain intensity at the 3 months follow-up, favouring the EDU+EXE group (mean SD change: -25.4±26.7 vs -6.6±30.7, p<0.005). At patient-level response, there were differences in the response rates and patterns. In the EDU+EXE group, the proportion of patients that experienced substantial pain relief (>50%) raised from 47% to 70%, at 3 and 12 weeks, respectively. In the EXE group this proportion raised from 25% to 34% (Relative risk of 1.87, and 2.04 respectively). At 3 weeks, 41% of the participants in the EXE group achieved a level of response of “no important change” (<15%) compared to 27% in the EDU+EXE group. In the EDU+EXE group, and for those who achieved a pain relief of at least 50% at 3 weeks, the rate of sustained pain relief response was approximately 93% and 86%, at 6 and 12 weeks respectively. These rates were higher than those of 63% and 50% found in the EXE group. Conclusion: This study’s findings support the provision of pain neuroscience education as a clinically effective addition to aquatic exercise. Individual response analysis showed that the patients receiving EDU+EXE achieved an early response to pain, had higher response rates at all the endpoints and were also more likely to achieve a sustained response over time compared to those receiving EXE only. Implications: Intervention studies should examine patient-level responses in addition to average treatment effects in order to enhance the clinical decision-making and patient communication.