15 years after George W Bush created the multibillion dollar US President's Emergency Plan for AIDS Relief (PEPFAR) to treat HIV infections worldwide, it can be hard to recall the horrors of bearing witness to AIDS carnage. In the absence of effective treatment, there was a time of walking corpses, of young adults and their babies staggering through final days in terrible pain. The hopelessness of the time, from 1981 to 1996 in high-income countries and another 6 years in Africa, often weighed on the souls of scientists, physicians, nurses, activists, and chroniclers in its maelstrom.
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Thursday, July 26, 2018
Subgroup perspectives on chronic pain and its management after spinal cord injury
Up to 80% of individuals develop chronic pain within their first year after a spinal cord injury (SCI).12 Although all pain types that occur after injury can be problematic, the persistent neuropathic pain types in particular, negatively influence quality of life and independent living after SCI by interfering with sleep, mood, physical and social activities.33,3,53,29,22,21,47 Because most pharmacological approaches only have limited effectiveness in reducing the intensity and impact of neuropathic pain in this population, optimal pain management strategies need to incorporate multiple ways to reduce pain.
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Tuesday, July 24, 2018
Do Patients With Carpal Tunnel Syndrome Benefit From Low-Level Laser Therapy? A Systematic Review of Randomized Controlled Trials
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Thierry P. Franke, Bart W. Koes, Sven J. Geelen, Bionka M. Huisstede
Abstract
Objective
To systematically review the literature on the effectiveness of low-level laser therapy for patients with carpal tunnel syndrome.
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the 2 systematic reviews and 17 RCTs that were included. Strong evidence was found for the effectiveness of low-level laser therapy compared with placebo treatment in the very short term (0 to ≤5wk). After 5 weeks, the positive effects of low-level laser therapy on pain, function, or recovery diminished over time (moderate and conflicting evidence were found at 7- and 12-wk follow-up, respectively).
Conclusions
In the very short term, low-level laser therapy is more effective as a single intervention than placebo low-level laser therapy in patients with carpal tunnel syndrome, after which the positive effects of low-level laser therapy tend to subside. Evidence in the midterm and long term is sparse.
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Effectiveness of Oral Pain Medication and Corticosteroid Injections for Carpal Tunnel Syndrome: A Systematic Review
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Bionka M. Huisstede, Manon S. Randsdorp, Janneke van den Brink, Thierry P.C. Franke, Bart W. Koes, Peter Hoogvliet
Abstract
Objective
To present an evidence-based overview of the effectiveness of oral pain medication and corticosteroid injections to treat carpal tunnel syndrome (CTS).
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs).
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data on pain (visual analog scale), function or recovery, and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the included studies. Four reviews and 9 RCTs were included. For oral pain medication, strong and moderate evidence was found for the effectiveness of oral steroids versus placebo in the short term. Moderate evidence was found in favor of oral steroids versus splinting in the short term. No evidence was found for the effectiveness of oral steroids in the long term. For corticosteroid injections, strong evidence was found in favor of a corticosteroid injection versus a placebo injection and moderate evidence was found in favor of corticosteroid injection versus oral steroids in the short term. Also, in the short term, moderate evidence was found in favor of a local versus a systematic corticosteroid injection. Higher doses of corticosteroid injections seem to be more effective in the midterm; however, the benefits of corticosteroid injections were not maintained in the long term.
Conclusions
The reviewed evidence supports that oral steroids and corticosteroid injections benefit patient with CTS particularly in the short term. Although a higher dose of steroid injections seems to be more effective in the midterm, the benefits of oral pain medication and corticosteroid injections were not maintained in the long term.
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Gait Training in Acute Spinal Cord Injury Rehabilitation—Utilization and Outcomes Among Nonambulatory Individuals: Findings From the SCIRehab Project
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Stephanie Rigot, Lynn Worobey, Michael L. Boninger
Abstract
Objectives
To investigate the relation of gait training (GT) during inpatient rehabilitation (IPR) to outcomes of people with traumatic spinal cord injury (SCI).
Design
Prospective observational study using the SCIRehab database.
Setting
Six IPR facilities.
Participants
Patients with new SCI (N=1376) receiving initial rehabilitation.
Interventions
Patients were divided into groups consisting of those who did and did not receive GT. Patients were further subdivided based on their primary mode of mobility as measured by the FIM.
Main Outcome Measures
Pain rating scales, Patient Health Questionnaire Mood Subscale, Satisfaction With Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART).
Results
Nearly 58% of all patients received GT, including 33.3% of patients who were primarily using a wheelchair 1 year after discharge from IPR. Those who used a wheelchair and received GT, received significantly less transfer and wheeled mobility training (P<.001). CHART physical independence (P=.002), mobility (P=.024), and occupation (P=.003) scores were significantly worse in patients who used a wheelchair at 1 year and received GT, compared with those who used a wheelchair and did not receive GT in IPR. Older age was also a significant predictor of worse participation as measured by the CHART.
Conclusions
A significant percentage of individuals who are not likely to become functional ambulators are spending portions of their IPR stays performing GT, which is associated with less time allotted for other functional interventions. GT in IPR was also associated with participation deficits at 1 year for those who used a wheelchair, implying the potential consequences of opportunity costs, pain, and psychological difficulties of receiving unsuccessful GT. Clinicians should consider these data when deciding to implement GT during initial IPR.
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Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Pradeep Suri, Kristin Delaney, Sean D. Rundell, Daniel C. Cherkin
Abstract
Objective
To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care.
Design
Secondary analysis of data from participants receiving usual care in a randomized clinical trial.
Setting
Primary care clinics.
Participants
Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included.
Interventions
Not applicable.
Main Outcome Measures
The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up.
Results
The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group.
Conclusions
The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.
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The Effects of Neck-Specific Training versus Prescribed Physical Activity on Pain and Disability in Patients with Cervical Radiculopathy: A Randomized Clinical Trial
Publication date: Available online 4 July 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Åsa Dedering, Anneli Peolsson, Joshua A. Cleland, Marie Halvorsen, Mikael Svensson, Marie Kierkegaard
Abstract
Objective
To compare the effects of a neck-specific training program to prescribed physical activity with both groups receiving a cognitive behavioral approach, on pain and disability in patients with cervical radiculopathy (CR).
Design
Parallel-group randomized clinical trial with follow-up at 3, 6, 12 and 24 months.
Setting
Recruitment and assessments of participants were performed at a university hospital. Interventions were performed in primary care setting at outpatient physiotherapy clinics.
Participants
A total of 144 patients with CR were recruited to participate in this clinical trial.
Interventions
Patients were randomly assigned to 3 months of either of a neck-specific training program or prescribed physical activity.
Main Outcome measures
Primary outcomes included self-rated neck and arm pain as collected by the Visual Analogue Scale (VAS). Secondary outcomes were self-rated headache measured with the VAS, the Neck Disability Index, the EuroQol 5D, the Fear Avoidance Beliefs Questionnaire and the Hospital Anxiety and Depression Scale. Assessments were performed at baseline and at 3, 6, 12 and 24 months follow-up periods.
Results
Intention-to-treat and per-protocol analyses showed no significant interaction (group*time) or group effects. There were, however, significant time effects indicating improvement over time for both groups for all outcomes except for levels of depression.
Conclusion
The study revealed that neck-specific training as well as prescribed physical activity both including additional cognitive behavioural approach decreased the pain in patients with CR i.e. participants improved regardless of the intervention received. There is a lack of consensus of how to best manage individuals with CR. However, our findings suggest that CR has a natural favorable long-term outcome when patients are prescribed neck specific training and exercise in combination with a behavioral approach.
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Hip Symptoms, Physical Performance, and Health Status in Older Adults With Chronic Low Back Pain: A Preliminary Investigation
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Gregory E. Hicks, J. Megan Sions, Teonette O. Velasco
Abstract
Objectives
To determine (1) whether there are differences in the prevalence of clinical hip symptoms between older adults with and without chronic low back pain (CLBP); and (2) whether coexisting hip symptoms are associated with worse physical performance and poorer health-related quality of life (HRQOL).
Design
Case-control study.
Setting
Individuals participated in a standardized evaluation in a clinical laboratory.
Participants
Clinical hip symptoms, which are proposed predictors of radiographic hip osteoarthritis according to American College of Rheumatology guidelines, were evaluated in a volunteer sample of community-dwelling older adults with CLBP (n=54; aged 60–85y) and in age- and sex-matched healthy controls (n=54).
Interventions
Not applicable.
Main Outcome Measures
Physical performance was measured by the repeated chair rise test and stair-climbing test. HRQOL was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).
Results
Hip joint pain, morning stiffness, and pain with hip internal rotation were more common among older adults with CLBP (P<.05). Participants with CLBP and coexisting hip symptoms had worse physical performance than individuals without CLBP or hip symptoms (P<.0001). Additionally, the presence of coexisting hip symptoms was associated with worse HRQOL, particularly in the domains of social functioning, mental health, and role limitations attributable to emotional problems as measured by the SF-36 (P<.01).
Conclusions
Given our limited understanding of CLBP among older adults, there is a definitive need to systematically explore coexisting pain conditions that may contribute to worse outcomes. Based on these data, future longitudinal studies should explore whether coexisting hip symptoms are associated with a worse prognosis in older adults with CLBP.
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Moderators of Treatment Outcomes After Telehealth Self-Management and Education in Adults With Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Dawn M. Ehde, Anne Arewasikporn, Kevin N. Alschuler, Abbey J. Hughes, Aaron P. Turner
Abstract
Objective
To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS.
Design
Secondary analysis of a single-blind randomized controlled trial.
Setting
Community.
Participants
Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States.
Interventions
Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88).
Main Outcome Measures
Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation).
Results
Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes.
Conclusions
At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms.
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Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Louise M. Fuller, Doa El-Ansary, Brenda M. Button, Monique Corbett, Greg Snell, Silvana Marasco, Anne E. Holland
Abstract
Objective
To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx).
Design
Randomized controlled trial.
Setting
Physiotherapy gym.
Participants
Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx.
Interventions
All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment.
Main Outcome Measures
Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors.
Results
After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P<.001) as well as greater UL strength than did participants in the NULP (mean peak force, 8.4±4.0Nm vs 6.7±2.8Nm; P=.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P=.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported.
Conclusions
UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.
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Do Patients With Carpal Tunnel Syndrome Benefit From Low-Level Laser Therapy? A Systematic Review of Randomized Controlled Trials
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Thierry P. Franke, Bart W. Koes, Sven J. Geelen, Bionka M. Huisstede
Abstract
Objective
To systematically review the literature on the effectiveness of low-level laser therapy for patients with carpal tunnel syndrome.
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the 2 systematic reviews and 17 RCTs that were included. Strong evidence was found for the effectiveness of low-level laser therapy compared with placebo treatment in the very short term (0 to ≤5wk). After 5 weeks, the positive effects of low-level laser therapy on pain, function, or recovery diminished over time (moderate and conflicting evidence were found at 7- and 12-wk follow-up, respectively).
Conclusions
In the very short term, low-level laser therapy is more effective as a single intervention than placebo low-level laser therapy in patients with carpal tunnel syndrome, after which the positive effects of low-level laser therapy tend to subside. Evidence in the midterm and long term is sparse.
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via IFTTT
Effectiveness of Oral Pain Medication and Corticosteroid Injections for Carpal Tunnel Syndrome: A Systematic Review
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Bionka M. Huisstede, Manon S. Randsdorp, Janneke van den Brink, Thierry P.C. Franke, Bart W. Koes, Peter Hoogvliet
Abstract
Objective
To present an evidence-based overview of the effectiveness of oral pain medication and corticosteroid injections to treat carpal tunnel syndrome (CTS).
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs).
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data on pain (visual analog scale), function or recovery, and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the included studies. Four reviews and 9 RCTs were included. For oral pain medication, strong and moderate evidence was found for the effectiveness of oral steroids versus placebo in the short term. Moderate evidence was found in favor of oral steroids versus splinting in the short term. No evidence was found for the effectiveness of oral steroids in the long term. For corticosteroid injections, strong evidence was found in favor of a corticosteroid injection versus a placebo injection and moderate evidence was found in favor of corticosteroid injection versus oral steroids in the short term. Also, in the short term, moderate evidence was found in favor of a local versus a systematic corticosteroid injection. Higher doses of corticosteroid injections seem to be more effective in the midterm; however, the benefits of corticosteroid injections were not maintained in the long term.
Conclusions
The reviewed evidence supports that oral steroids and corticosteroid injections benefit patient with CTS particularly in the short term. Although a higher dose of steroid injections seems to be more effective in the midterm, the benefits of oral pain medication and corticosteroid injections were not maintained in the long term.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2A7DOiN
via IFTTT
Gait Training in Acute Spinal Cord Injury Rehabilitation—Utilization and Outcomes Among Nonambulatory Individuals: Findings From the SCIRehab Project
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Stephanie Rigot, Lynn Worobey, Michael L. Boninger
Abstract
Objectives
To investigate the relation of gait training (GT) during inpatient rehabilitation (IPR) to outcomes of people with traumatic spinal cord injury (SCI).
Design
Prospective observational study using the SCIRehab database.
Setting
Six IPR facilities.
Participants
Patients with new SCI (N=1376) receiving initial rehabilitation.
Interventions
Patients were divided into groups consisting of those who did and did not receive GT. Patients were further subdivided based on their primary mode of mobility as measured by the FIM.
Main Outcome Measures
Pain rating scales, Patient Health Questionnaire Mood Subscale, Satisfaction With Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART).
Results
Nearly 58% of all patients received GT, including 33.3% of patients who were primarily using a wheelchair 1 year after discharge from IPR. Those who used a wheelchair and received GT, received significantly less transfer and wheeled mobility training (P<.001). CHART physical independence (P=.002), mobility (P=.024), and occupation (P=.003) scores were significantly worse in patients who used a wheelchair at 1 year and received GT, compared with those who used a wheelchair and did not receive GT in IPR. Older age was also a significant predictor of worse participation as measured by the CHART.
Conclusions
A significant percentage of individuals who are not likely to become functional ambulators are spending portions of their IPR stays performing GT, which is associated with less time allotted for other functional interventions. GT in IPR was also associated with participation deficits at 1 year for those who used a wheelchair, implying the potential consequences of opportunity costs, pain, and psychological difficulties of receiving unsuccessful GT. Clinicians should consider these data when deciding to implement GT during initial IPR.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2Ohsp2T
via IFTTT
Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Pradeep Suri, Kristin Delaney, Sean D. Rundell, Daniel C. Cherkin
Abstract
Objective
To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care.
Design
Secondary analysis of data from participants receiving usual care in a randomized clinical trial.
Setting
Primary care clinics.
Participants
Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included.
Interventions
Not applicable.
Main Outcome Measures
The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up.
Results
The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group.
Conclusions
The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2A5wgNF
via IFTTT
The Effects of Neck-Specific Training versus Prescribed Physical Activity on Pain and Disability in Patients with Cervical Radiculopathy: A Randomized Clinical Trial
Publication date: Available online 4 July 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Åsa Dedering, Anneli Peolsson, Joshua A. Cleland, Marie Halvorsen, Mikael Svensson, Marie Kierkegaard
Abstract
Objective
To compare the effects of a neck-specific training program to prescribed physical activity with both groups receiving a cognitive behavioral approach, on pain and disability in patients with cervical radiculopathy (CR).
Design
Parallel-group randomized clinical trial with follow-up at 3, 6, 12 and 24 months.
Setting
Recruitment and assessments of participants were performed at a university hospital. Interventions were performed in primary care setting at outpatient physiotherapy clinics.
Participants
A total of 144 patients with CR were recruited to participate in this clinical trial.
Interventions
Patients were randomly assigned to 3 months of either of a neck-specific training program or prescribed physical activity.
Main Outcome measures
Primary outcomes included self-rated neck and arm pain as collected by the Visual Analogue Scale (VAS). Secondary outcomes were self-rated headache measured with the VAS, the Neck Disability Index, the EuroQol 5D, the Fear Avoidance Beliefs Questionnaire and the Hospital Anxiety and Depression Scale. Assessments were performed at baseline and at 3, 6, 12 and 24 months follow-up periods.
Results
Intention-to-treat and per-protocol analyses showed no significant interaction (group*time) or group effects. There were, however, significant time effects indicating improvement over time for both groups for all outcomes except for levels of depression.
Conclusion
The study revealed that neck-specific training as well as prescribed physical activity both including additional cognitive behavioural approach decreased the pain in patients with CR i.e. participants improved regardless of the intervention received. There is a lack of consensus of how to best manage individuals with CR. However, our findings suggest that CR has a natural favorable long-term outcome when patients are prescribed neck specific training and exercise in combination with a behavioral approach.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2OdSSOR
via IFTTT
Hip Symptoms, Physical Performance, and Health Status in Older Adults With Chronic Low Back Pain: A Preliminary Investigation
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Gregory E. Hicks, J. Megan Sions, Teonette O. Velasco
Abstract
Objectives
To determine (1) whether there are differences in the prevalence of clinical hip symptoms between older adults with and without chronic low back pain (CLBP); and (2) whether coexisting hip symptoms are associated with worse physical performance and poorer health-related quality of life (HRQOL).
Design
Case-control study.
Setting
Individuals participated in a standardized evaluation in a clinical laboratory.
Participants
Clinical hip symptoms, which are proposed predictors of radiographic hip osteoarthritis according to American College of Rheumatology guidelines, were evaluated in a volunteer sample of community-dwelling older adults with CLBP (n=54; aged 60–85y) and in age- and sex-matched healthy controls (n=54).
Interventions
Not applicable.
Main Outcome Measures
Physical performance was measured by the repeated chair rise test and stair-climbing test. HRQOL was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).
Results
Hip joint pain, morning stiffness, and pain with hip internal rotation were more common among older adults with CLBP (P<.05). Participants with CLBP and coexisting hip symptoms had worse physical performance than individuals without CLBP or hip symptoms (P<.0001). Additionally, the presence of coexisting hip symptoms was associated with worse HRQOL, particularly in the domains of social functioning, mental health, and role limitations attributable to emotional problems as measured by the SF-36 (P<.01).
Conclusions
Given our limited understanding of CLBP among older adults, there is a definitive need to systematically explore coexisting pain conditions that may contribute to worse outcomes. Based on these data, future longitudinal studies should explore whether coexisting hip symptoms are associated with a worse prognosis in older adults with CLBP.
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via IFTTT
Moderators of Treatment Outcomes After Telehealth Self-Management and Education in Adults With Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Dawn M. Ehde, Anne Arewasikporn, Kevin N. Alschuler, Abbey J. Hughes, Aaron P. Turner
Abstract
Objective
To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS.
Design
Secondary analysis of a single-blind randomized controlled trial.
Setting
Community.
Participants
Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States.
Interventions
Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88).
Main Outcome Measures
Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation).
Results
Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes.
Conclusions
At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2mEqdWu
via IFTTT
Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Louise M. Fuller, Doa El-Ansary, Brenda M. Button, Monique Corbett, Greg Snell, Silvana Marasco, Anne E. Holland
Abstract
Objective
To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx).
Design
Randomized controlled trial.
Setting
Physiotherapy gym.
Participants
Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx.
Interventions
All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment.
Main Outcome Measures
Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors.
Results
After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P<.001) as well as greater UL strength than did participants in the NULP (mean peak force, 8.4±4.0Nm vs 6.7±2.8Nm; P=.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P=.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported.
Conclusions
UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.
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Do Patients With Carpal Tunnel Syndrome Benefit From Low-Level Laser Therapy? A Systematic Review of Randomized Controlled Trials
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Thierry P. Franke, Bart W. Koes, Sven J. Geelen, Bionka M. Huisstede
Abstract
Objective
To systematically review the literature on the effectiveness of low-level laser therapy for patients with carpal tunnel syndrome.
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the 2 systematic reviews and 17 RCTs that were included. Strong evidence was found for the effectiveness of low-level laser therapy compared with placebo treatment in the very short term (0 to ≤5wk). After 5 weeks, the positive effects of low-level laser therapy on pain, function, or recovery diminished over time (moderate and conflicting evidence were found at 7- and 12-wk follow-up, respectively).
Conclusions
In the very short term, low-level laser therapy is more effective as a single intervention than placebo low-level laser therapy in patients with carpal tunnel syndrome, after which the positive effects of low-level laser therapy tend to subside. Evidence in the midterm and long term is sparse.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2mFhVxH
via IFTTT
Effectiveness of Oral Pain Medication and Corticosteroid Injections for Carpal Tunnel Syndrome: A Systematic Review
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Bionka M. Huisstede, Manon S. Randsdorp, Janneke van den Brink, Thierry P.C. Franke, Bart W. Koes, Peter Hoogvliet
Abstract
Objective
To present an evidence-based overview of the effectiveness of oral pain medication and corticosteroid injections to treat carpal tunnel syndrome (CTS).
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs).
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data on pain (visual analog scale), function or recovery, and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the included studies. Four reviews and 9 RCTs were included. For oral pain medication, strong and moderate evidence was found for the effectiveness of oral steroids versus placebo in the short term. Moderate evidence was found in favor of oral steroids versus splinting in the short term. No evidence was found for the effectiveness of oral steroids in the long term. For corticosteroid injections, strong evidence was found in favor of a corticosteroid injection versus a placebo injection and moderate evidence was found in favor of corticosteroid injection versus oral steroids in the short term. Also, in the short term, moderate evidence was found in favor of a local versus a systematic corticosteroid injection. Higher doses of corticosteroid injections seem to be more effective in the midterm; however, the benefits of corticosteroid injections were not maintained in the long term.
Conclusions
The reviewed evidence supports that oral steroids and corticosteroid injections benefit patient with CTS particularly in the short term. Although a higher dose of steroid injections seems to be more effective in the midterm, the benefits of oral pain medication and corticosteroid injections were not maintained in the long term.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2A7DOiN
via IFTTT
Gait Training in Acute Spinal Cord Injury Rehabilitation—Utilization and Outcomes Among Nonambulatory Individuals: Findings From the SCIRehab Project
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Stephanie Rigot, Lynn Worobey, Michael L. Boninger
Abstract
Objectives
To investigate the relation of gait training (GT) during inpatient rehabilitation (IPR) to outcomes of people with traumatic spinal cord injury (SCI).
Design
Prospective observational study using the SCIRehab database.
Setting
Six IPR facilities.
Participants
Patients with new SCI (N=1376) receiving initial rehabilitation.
Interventions
Patients were divided into groups consisting of those who did and did not receive GT. Patients were further subdivided based on their primary mode of mobility as measured by the FIM.
Main Outcome Measures
Pain rating scales, Patient Health Questionnaire Mood Subscale, Satisfaction With Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART).
Results
Nearly 58% of all patients received GT, including 33.3% of patients who were primarily using a wheelchair 1 year after discharge from IPR. Those who used a wheelchair and received GT, received significantly less transfer and wheeled mobility training (P<.001). CHART physical independence (P=.002), mobility (P=.024), and occupation (P=.003) scores were significantly worse in patients who used a wheelchair at 1 year and received GT, compared with those who used a wheelchair and did not receive GT in IPR. Older age was also a significant predictor of worse participation as measured by the CHART.
Conclusions
A significant percentage of individuals who are not likely to become functional ambulators are spending portions of their IPR stays performing GT, which is associated with less time allotted for other functional interventions. GT in IPR was also associated with participation deficits at 1 year for those who used a wheelchair, implying the potential consequences of opportunity costs, pain, and psychological difficulties of receiving unsuccessful GT. Clinicians should consider these data when deciding to implement GT during initial IPR.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2Ohsp2T
via IFTTT
Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Pradeep Suri, Kristin Delaney, Sean D. Rundell, Daniel C. Cherkin
Abstract
Objective
To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care.
Design
Secondary analysis of data from participants receiving usual care in a randomized clinical trial.
Setting
Primary care clinics.
Participants
Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included.
Interventions
Not applicable.
Main Outcome Measures
The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up.
Results
The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group.
Conclusions
The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2A5wgNF
via IFTTT
The Effects of Neck-Specific Training versus Prescribed Physical Activity on Pain and Disability in Patients with Cervical Radiculopathy: A Randomized Clinical Trial
Publication date: Available online 4 July 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Åsa Dedering, Anneli Peolsson, Joshua A. Cleland, Marie Halvorsen, Mikael Svensson, Marie Kierkegaard
Abstract
Objective
To compare the effects of a neck-specific training program to prescribed physical activity with both groups receiving a cognitive behavioral approach, on pain and disability in patients with cervical radiculopathy (CR).
Design
Parallel-group randomized clinical trial with follow-up at 3, 6, 12 and 24 months.
Setting
Recruitment and assessments of participants were performed at a university hospital. Interventions were performed in primary care setting at outpatient physiotherapy clinics.
Participants
A total of 144 patients with CR were recruited to participate in this clinical trial.
Interventions
Patients were randomly assigned to 3 months of either of a neck-specific training program or prescribed physical activity.
Main Outcome measures
Primary outcomes included self-rated neck and arm pain as collected by the Visual Analogue Scale (VAS). Secondary outcomes were self-rated headache measured with the VAS, the Neck Disability Index, the EuroQol 5D, the Fear Avoidance Beliefs Questionnaire and the Hospital Anxiety and Depression Scale. Assessments were performed at baseline and at 3, 6, 12 and 24 months follow-up periods.
Results
Intention-to-treat and per-protocol analyses showed no significant interaction (group*time) or group effects. There were, however, significant time effects indicating improvement over time for both groups for all outcomes except for levels of depression.
Conclusion
The study revealed that neck-specific training as well as prescribed physical activity both including additional cognitive behavioural approach decreased the pain in patients with CR i.e. participants improved regardless of the intervention received. There is a lack of consensus of how to best manage individuals with CR. However, our findings suggest that CR has a natural favorable long-term outcome when patients are prescribed neck specific training and exercise in combination with a behavioral approach.
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via IFTTT
Hip Symptoms, Physical Performance, and Health Status in Older Adults With Chronic Low Back Pain: A Preliminary Investigation
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Gregory E. Hicks, J. Megan Sions, Teonette O. Velasco
Abstract
Objectives
To determine (1) whether there are differences in the prevalence of clinical hip symptoms between older adults with and without chronic low back pain (CLBP); and (2) whether coexisting hip symptoms are associated with worse physical performance and poorer health-related quality of life (HRQOL).
Design
Case-control study.
Setting
Individuals participated in a standardized evaluation in a clinical laboratory.
Participants
Clinical hip symptoms, which are proposed predictors of radiographic hip osteoarthritis according to American College of Rheumatology guidelines, were evaluated in a volunteer sample of community-dwelling older adults with CLBP (n=54; aged 60–85y) and in age- and sex-matched healthy controls (n=54).
Interventions
Not applicable.
Main Outcome Measures
Physical performance was measured by the repeated chair rise test and stair-climbing test. HRQOL was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).
Results
Hip joint pain, morning stiffness, and pain with hip internal rotation were more common among older adults with CLBP (P<.05). Participants with CLBP and coexisting hip symptoms had worse physical performance than individuals without CLBP or hip symptoms (P<.0001). Additionally, the presence of coexisting hip symptoms was associated with worse HRQOL, particularly in the domains of social functioning, mental health, and role limitations attributable to emotional problems as measured by the SF-36 (P<.01).
Conclusions
Given our limited understanding of CLBP among older adults, there is a definitive need to systematically explore coexisting pain conditions that may contribute to worse outcomes. Based on these data, future longitudinal studies should explore whether coexisting hip symptoms are associated with a worse prognosis in older adults with CLBP.
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via IFTTT
Moderators of Treatment Outcomes After Telehealth Self-Management and Education in Adults With Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Dawn M. Ehde, Anne Arewasikporn, Kevin N. Alschuler, Abbey J. Hughes, Aaron P. Turner
Abstract
Objective
To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS.
Design
Secondary analysis of a single-blind randomized controlled trial.
Setting
Community.
Participants
Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States.
Interventions
Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88).
Main Outcome Measures
Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation).
Results
Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes.
Conclusions
At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms.
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via IFTTT
Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Louise M. Fuller, Doa El-Ansary, Brenda M. Button, Monique Corbett, Greg Snell, Silvana Marasco, Anne E. Holland
Abstract
Objective
To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx).
Design
Randomized controlled trial.
Setting
Physiotherapy gym.
Participants
Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx.
Interventions
All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment.
Main Outcome Measures
Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors.
Results
After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P<.001) as well as greater UL strength than did participants in the NULP (mean peak force, 8.4±4.0Nm vs 6.7±2.8Nm; P=.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P=.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported.
Conclusions
UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2A89GUy
via IFTTT
Do Patients With Carpal Tunnel Syndrome Benefit From Low-Level Laser Therapy? A Systematic Review of Randomized Controlled Trials
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Thierry P. Franke, Bart W. Koes, Sven J. Geelen, Bionka M. Huisstede
Abstract
Objective
To systematically review the literature on the effectiveness of low-level laser therapy for patients with carpal tunnel syndrome.
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the 2 systematic reviews and 17 RCTs that were included. Strong evidence was found for the effectiveness of low-level laser therapy compared with placebo treatment in the very short term (0 to ≤5wk). After 5 weeks, the positive effects of low-level laser therapy on pain, function, or recovery diminished over time (moderate and conflicting evidence were found at 7- and 12-wk follow-up, respectively).
Conclusions
In the very short term, low-level laser therapy is more effective as a single intervention than placebo low-level laser therapy in patients with carpal tunnel syndrome, after which the positive effects of low-level laser therapy tend to subside. Evidence in the midterm and long term is sparse.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2mFhVxH
via IFTTT
Effectiveness of Oral Pain Medication and Corticosteroid Injections for Carpal Tunnel Syndrome: A Systematic Review
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Bionka M. Huisstede, Manon S. Randsdorp, Janneke van den Brink, Thierry P.C. Franke, Bart W. Koes, Peter Hoogvliet
Abstract
Objective
To present an evidence-based overview of the effectiveness of oral pain medication and corticosteroid injections to treat carpal tunnel syndrome (CTS).
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs).
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data on pain (visual analog scale), function or recovery, and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the included studies. Four reviews and 9 RCTs were included. For oral pain medication, strong and moderate evidence was found for the effectiveness of oral steroids versus placebo in the short term. Moderate evidence was found in favor of oral steroids versus splinting in the short term. No evidence was found for the effectiveness of oral steroids in the long term. For corticosteroid injections, strong evidence was found in favor of a corticosteroid injection versus a placebo injection and moderate evidence was found in favor of corticosteroid injection versus oral steroids in the short term. Also, in the short term, moderate evidence was found in favor of a local versus a systematic corticosteroid injection. Higher doses of corticosteroid injections seem to be more effective in the midterm; however, the benefits of corticosteroid injections were not maintained in the long term.
Conclusions
The reviewed evidence supports that oral steroids and corticosteroid injections benefit patient with CTS particularly in the short term. Although a higher dose of steroid injections seems to be more effective in the midterm, the benefits of oral pain medication and corticosteroid injections were not maintained in the long term.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2A7DOiN
via IFTTT
Gait Training in Acute Spinal Cord Injury Rehabilitation—Utilization and Outcomes Among Nonambulatory Individuals: Findings From the SCIRehab Project
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Stephanie Rigot, Lynn Worobey, Michael L. Boninger
Abstract
Objectives
To investigate the relation of gait training (GT) during inpatient rehabilitation (IPR) to outcomes of people with traumatic spinal cord injury (SCI).
Design
Prospective observational study using the SCIRehab database.
Setting
Six IPR facilities.
Participants
Patients with new SCI (N=1376) receiving initial rehabilitation.
Interventions
Patients were divided into groups consisting of those who did and did not receive GT. Patients were further subdivided based on their primary mode of mobility as measured by the FIM.
Main Outcome Measures
Pain rating scales, Patient Health Questionnaire Mood Subscale, Satisfaction With Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART).
Results
Nearly 58% of all patients received GT, including 33.3% of patients who were primarily using a wheelchair 1 year after discharge from IPR. Those who used a wheelchair and received GT, received significantly less transfer and wheeled mobility training (P<.001). CHART physical independence (P=.002), mobility (P=.024), and occupation (P=.003) scores were significantly worse in patients who used a wheelchair at 1 year and received GT, compared with those who used a wheelchair and did not receive GT in IPR. Older age was also a significant predictor of worse participation as measured by the CHART.
Conclusions
A significant percentage of individuals who are not likely to become functional ambulators are spending portions of their IPR stays performing GT, which is associated with less time allotted for other functional interventions. GT in IPR was also associated with participation deficits at 1 year for those who used a wheelchair, implying the potential consequences of opportunity costs, pain, and psychological difficulties of receiving unsuccessful GT. Clinicians should consider these data when deciding to implement GT during initial IPR.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2Ohsp2T
via IFTTT
Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Pradeep Suri, Kristin Delaney, Sean D. Rundell, Daniel C. Cherkin
Abstract
Objective
To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care.
Design
Secondary analysis of data from participants receiving usual care in a randomized clinical trial.
Setting
Primary care clinics.
Participants
Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included.
Interventions
Not applicable.
Main Outcome Measures
The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up.
Results
The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group.
Conclusions
The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2A5wgNF
via IFTTT
The Effects of Neck-Specific Training versus Prescribed Physical Activity on Pain and Disability in Patients with Cervical Radiculopathy: A Randomized Clinical Trial
Publication date: Available online 4 July 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Åsa Dedering, Anneli Peolsson, Joshua A. Cleland, Marie Halvorsen, Mikael Svensson, Marie Kierkegaard
Abstract
Objective
To compare the effects of a neck-specific training program to prescribed physical activity with both groups receiving a cognitive behavioral approach, on pain and disability in patients with cervical radiculopathy (CR).
Design
Parallel-group randomized clinical trial with follow-up at 3, 6, 12 and 24 months.
Setting
Recruitment and assessments of participants were performed at a university hospital. Interventions were performed in primary care setting at outpatient physiotherapy clinics.
Participants
A total of 144 patients with CR were recruited to participate in this clinical trial.
Interventions
Patients were randomly assigned to 3 months of either of a neck-specific training program or prescribed physical activity.
Main Outcome measures
Primary outcomes included self-rated neck and arm pain as collected by the Visual Analogue Scale (VAS). Secondary outcomes were self-rated headache measured with the VAS, the Neck Disability Index, the EuroQol 5D, the Fear Avoidance Beliefs Questionnaire and the Hospital Anxiety and Depression Scale. Assessments were performed at baseline and at 3, 6, 12 and 24 months follow-up periods.
Results
Intention-to-treat and per-protocol analyses showed no significant interaction (group*time) or group effects. There were, however, significant time effects indicating improvement over time for both groups for all outcomes except for levels of depression.
Conclusion
The study revealed that neck-specific training as well as prescribed physical activity both including additional cognitive behavioural approach decreased the pain in patients with CR i.e. participants improved regardless of the intervention received. There is a lack of consensus of how to best manage individuals with CR. However, our findings suggest that CR has a natural favorable long-term outcome when patients are prescribed neck specific training and exercise in combination with a behavioral approach.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2OdSSOR
via IFTTT
Hip Symptoms, Physical Performance, and Health Status in Older Adults With Chronic Low Back Pain: A Preliminary Investigation
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Gregory E. Hicks, J. Megan Sions, Teonette O. Velasco
Abstract
Objectives
To determine (1) whether there are differences in the prevalence of clinical hip symptoms between older adults with and without chronic low back pain (CLBP); and (2) whether coexisting hip symptoms are associated with worse physical performance and poorer health-related quality of life (HRQOL).
Design
Case-control study.
Setting
Individuals participated in a standardized evaluation in a clinical laboratory.
Participants
Clinical hip symptoms, which are proposed predictors of radiographic hip osteoarthritis according to American College of Rheumatology guidelines, were evaluated in a volunteer sample of community-dwelling older adults with CLBP (n=54; aged 60–85y) and in age- and sex-matched healthy controls (n=54).
Interventions
Not applicable.
Main Outcome Measures
Physical performance was measured by the repeated chair rise test and stair-climbing test. HRQOL was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).
Results
Hip joint pain, morning stiffness, and pain with hip internal rotation were more common among older adults with CLBP (P<.05). Participants with CLBP and coexisting hip symptoms had worse physical performance than individuals without CLBP or hip symptoms (P<.0001). Additionally, the presence of coexisting hip symptoms was associated with worse HRQOL, particularly in the domains of social functioning, mental health, and role limitations attributable to emotional problems as measured by the SF-36 (P<.01).
Conclusions
Given our limited understanding of CLBP among older adults, there is a definitive need to systematically explore coexisting pain conditions that may contribute to worse outcomes. Based on these data, future longitudinal studies should explore whether coexisting hip symptoms are associated with a worse prognosis in older adults with CLBP.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2A9CID9
via IFTTT
Moderators of Treatment Outcomes After Telehealth Self-Management and Education in Adults With Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Dawn M. Ehde, Anne Arewasikporn, Kevin N. Alschuler, Abbey J. Hughes, Aaron P. Turner
Abstract
Objective
To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS.
Design
Secondary analysis of a single-blind randomized controlled trial.
Setting
Community.
Participants
Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States.
Interventions
Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88).
Main Outcome Measures
Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation).
Results
Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes.
Conclusions
At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2mEqdWu
via IFTTT
Effect of Upper Limb Rehabilitation Compared to No Upper Limb Rehabilitation in Lung Transplant Recipients: A Randomized Controlled Trial
Publication date: July 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 7
Author(s): Louise M. Fuller, Doa El-Ansary, Brenda M. Button, Monique Corbett, Greg Snell, Silvana Marasco, Anne E. Holland
Abstract
Objective
To investigate the effect of a supervised upper limb (UL) program (SULP) compared to no supervised UL program (NULP) after lung transplantation (LTx).
Design
Randomized controlled trial.
Setting
Physiotherapy gym.
Participants
Participants (N=80; mean age, 56±11y; 37 [46%] men) were recruited after LTx.
Interventions
All participants underwent lower limb strength thrice weekly and endurance training. Participants randomized to SULP completed progressive UL strength training program using handheld weights and adjustable pulley equipment.
Main Outcome Measures
Overall bodily pain was rated on the visual analog scale. Shoulder flexion and abduction muscle strength were measured on a hand held dynamometer. Health related quality of life was measured with Medical Outcomes Study 36-item Short Form health Survey and the Quick Dash. Measurements were made at baseline, 6 weeks, 12 weeks, and 6 months by blinded assessors.
Results
After 6 weeks of training, participants in the SULP (n=41) had less overall bodily pain on the visual analog scale than did participants in the NULP (n=36) (mean VAS bodily pain score, 2.1±1.3cm vs 3.8±1.7cm; P<.001) as well as greater UL strength than did participants in the NULP (mean peak force, 8.4±4.0Nm vs 6.7±2.8Nm; P=.037). At 12 weeks, participants in the SULP better quality of life related to bodily pain (76±17 vs 66±26; P=.05), but at 6 months there were no differences between the groups in any outcome measures. No serious adverse events were reported.
Conclusions
UL rehabilitation results in short-term improvements in pain and muscle strength after LTx, but no longer-term effects were evident.
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Do Patients With Carpal Tunnel Syndrome Benefit From Low-Level Laser Therapy? A Systematic Review of Randomized Controlled Trials
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Thierry P. Franke, Bart W. Koes, Sven J. Geelen, Bionka M. Huisstede
Abstract
Objective
To systematically review the literature on the effectiveness of low-level laser therapy for patients with carpal tunnel syndrome.
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016.
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the 2 systematic reviews and 17 RCTs that were included. Strong evidence was found for the effectiveness of low-level laser therapy compared with placebo treatment in the very short term (0 to ≤5wk). After 5 weeks, the positive effects of low-level laser therapy on pain, function, or recovery diminished over time (moderate and conflicting evidence were found at 7- and 12-wk follow-up, respectively).
Conclusions
In the very short term, low-level laser therapy is more effective as a single intervention than placebo low-level laser therapy in patients with carpal tunnel syndrome, after which the positive effects of low-level laser therapy tend to subside. Evidence in the midterm and long term is sparse.
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Effectiveness of Oral Pain Medication and Corticosteroid Injections for Carpal Tunnel Syndrome: A Systematic Review
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Bionka M. Huisstede, Manon S. Randsdorp, Janneke van den Brink, Thierry P.C. Franke, Bart W. Koes, Peter Hoogvliet
Abstract
Objective
To present an evidence-based overview of the effectiveness of oral pain medication and corticosteroid injections to treat carpal tunnel syndrome (CTS).
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs).
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data on pain (visual analog scale), function or recovery, and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the included studies. Four reviews and 9 RCTs were included. For oral pain medication, strong and moderate evidence was found for the effectiveness of oral steroids versus placebo in the short term. Moderate evidence was found in favor of oral steroids versus splinting in the short term. No evidence was found for the effectiveness of oral steroids in the long term. For corticosteroid injections, strong evidence was found in favor of a corticosteroid injection versus a placebo injection and moderate evidence was found in favor of corticosteroid injection versus oral steroids in the short term. Also, in the short term, moderate evidence was found in favor of a local versus a systematic corticosteroid injection. Higher doses of corticosteroid injections seem to be more effective in the midterm; however, the benefits of corticosteroid injections were not maintained in the long term.
Conclusions
The reviewed evidence supports that oral steroids and corticosteroid injections benefit patient with CTS particularly in the short term. Although a higher dose of steroid injections seems to be more effective in the midterm, the benefits of oral pain medication and corticosteroid injections were not maintained in the long term.
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Gait Training in Acute Spinal Cord Injury Rehabilitation—Utilization and Outcomes Among Nonambulatory Individuals: Findings From the SCIRehab Project
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Stephanie Rigot, Lynn Worobey, Michael L. Boninger
Abstract
Objectives
To investigate the relation of gait training (GT) during inpatient rehabilitation (IPR) to outcomes of people with traumatic spinal cord injury (SCI).
Design
Prospective observational study using the SCIRehab database.
Setting
Six IPR facilities.
Participants
Patients with new SCI (N=1376) receiving initial rehabilitation.
Interventions
Patients were divided into groups consisting of those who did and did not receive GT. Patients were further subdivided based on their primary mode of mobility as measured by the FIM.
Main Outcome Measures
Pain rating scales, Patient Health Questionnaire Mood Subscale, Satisfaction With Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART).
Results
Nearly 58% of all patients received GT, including 33.3% of patients who were primarily using a wheelchair 1 year after discharge from IPR. Those who used a wheelchair and received GT, received significantly less transfer and wheeled mobility training (P<.001). CHART physical independence (P=.002), mobility (P=.024), and occupation (P=.003) scores were significantly worse in patients who used a wheelchair at 1 year and received GT, compared with those who used a wheelchair and did not receive GT in IPR. Older age was also a significant predictor of worse participation as measured by the CHART.
Conclusions
A significant percentage of individuals who are not likely to become functional ambulators are spending portions of their IPR stays performing GT, which is associated with less time allotted for other functional interventions. GT in IPR was also associated with participation deficits at 1 year for those who used a wheelchair, implying the potential consequences of opportunity costs, pain, and psychological difficulties of receiving unsuccessful GT. Clinicians should consider these data when deciding to implement GT during initial IPR.
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Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Pradeep Suri, Kristin Delaney, Sean D. Rundell, Daniel C. Cherkin
Abstract
Objective
To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care.
Design
Secondary analysis of data from participants receiving usual care in a randomized clinical trial.
Setting
Primary care clinics.
Participants
Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included.
Interventions
Not applicable.
Main Outcome Measures
The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up.
Results
The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group.
Conclusions
The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.
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Friday, July 20, 2018
You'd better believe it: The conceptual and practical challenges of assessing malingering in patients with chronic pain
Chronic pain is a prevalent and costly condition, with many patients receiving income support and funded treatment. Given that pain cannot be objectively assessed, patients may be suspected of exaggerating their pain and disability to receive additional funding. Although numerous methods of detecting malingering have been suggested, it is unclear whether clinicians can reliably identify malingering in patients with chronic pain. The present focus article was developed to assess the theoretical basis and empirical support for proposed methods of detecting malingering in patients with chronic pain.
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Sixty seconds on . . . kidney stones
Ouch!You can say that again. The discomfort caused by kidney stones passing through the ureter has been compared to birth contractions with pain radiating across the lower, abdomen, and groin. The...
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Thursday, July 19, 2018
[Clinical Picture] Hibernoma mimicking liposarcoma
A 26-year-old man was referred to the ophthalmology department with a 1-week history of blurred vision of the left eye; there was no pain or redness. Ophthalmological examination found unilateral choriocapillaropathy with optic nerve oedema. He was in a stable relationship and had not travelled abroad recently, nor had he been in contact with any animals or pets. He had a history of ulcerative colitis diagnosed 2 years earlier for which he was treated for 1 year with azathioprine and oral corticosteroids.
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A pain in the back
A 72 year old man with a history of atrial fibrillation was admitted with a basal ganglia interventricular haemorrhage. Warfarin was stopped on admission. Five days after presentation, he developed...
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Tuesday, July 17, 2018
Trigger point manual therapy for the treatment of chronic non-cancer pain in adults: a systematic review and meta-analysis
Publication date: Available online 17 July 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Diarmuid Denneny, Helena C. Frawley, Katrine Petersen, Rebecca McLoughlin, Suzanne Brook, Salma Hassan, Amanda C. de C Williams
Abstract
Objective
To determine the effectiveness of trigger point manual therapy (TPMT) for reducing chronic non-cancer pain and associated problems in adults, by analysing all relevant randomised controlled trials (RCTs).
Data Sources
We searched databases and clinical trials registers from their inception to May 2017.
Study Selection
We included RCTs in any language that recruited patients over the age of 18, with pain of three months duration or more. We assessed pain, function, and patient-reported improvement as outcomes.
Data Extraction
Two authors independently extracted and verified data. Meta-analysis was completed where possible, otherwise data were synthesised narratively.
Data Synthesis
We combined all data using a random-effects model and assessed the quality of evidence using GRADE. 19 trials (involving 1047 participants) met inclusion criteria, representing TPMT treatment for musculoskeletal, pelvic and facial pain. No effect was found for short-term pain relief (mean standardized difference -0.53, 95% CI -1.08 to 0.02). One small study showed a longer-term benefit for pain (mean standardized difference --2.00 (95% CI -3.40 to -0.60) but with low confidence in the effect. Significant gains emerged for function (mean standardized difference -0.77, 95% CI -1.27 to -0.26, and in patient global response (odds ratio 3.79, 95% CI 1.86 to 7.71) from four studies, but not for health-related quality of life.
Conclusions
Evidence for TPMT for chronic non-cancer pain is weak and it cannot currently be recommended.
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