Difference In Disability Scores Research Articles

P847 Insomnia is common in IBD and associated with increased disability and abdominal pain

Abstract Background Insomnia is common in those with chronic medical conditions. Insomnia is associated with decreased quality of life and is readily treatable through cognitive behavioural therapy for insomnia (CBTi). This study aimed to describe the associations with insomnia in an IBD population and its relationship with IBD related disability. Methods An online questionnaire was administered through three tertiary IBD centres, social media and through a patient advocacy group (Crohn’s Colitis Australia). The questionnaire included the insomnia index severity (ISI), a validated assessment of insomnia and its severity, with a score over 14 considered clinically significant insomnia. Validated measures of anxiety (GAD-7), depression (PHQ-9), physical activity (sIPAQ), and disability (IBD-DI-SR) were also utilised. IBD activity was assessed clinical IBD activity scores (HBI or SCCAI). Results There were 670 responses included in the analysis. Median age was 41 years (32-70), with the majority being female (78%), and 57% having Crohn’s disease. The mean disease duration was 11.9 years (10.4), 30% had undergone surgery for IBD and around half were on biologics (50.5%). The mean ISI score was 12.7 (6.09). Over a third of the cohort had at least moderate insomnia (ISI>15). A one-way ANOVA revealed differences in disability scores (IBD-DI-SR) (see table 1) between insomnia severity groups (F(3,619) = 20.99, p < 0.001), with disability scores worsening with increasing severity of insomnia. Multivariable logistic regression analysis (see table 2) revealed that clinically significant insomnia was significantly associated with clinically active IBD, abdominal pain, clinically significant anxiety, and clinically significant depression. Conclusion Insomnia is common in people with IBD with at least one third reporting moderate insomnia. Given that insomnia was associated with increased disability, consideration should be given for routine screening for insomnia in IBD patients. Mental health conditions and ongoing pain should be addressed with consideration given to referral for CBTi.

Remote Ischemic Conditioning May Improve Disability and Cognition After Acute Ischemic Stroke: A Pilot Randomized Clinical Trial.

Background and Aim: Remote ischemic conditioning is a procedure purported to reduce the ischemic injury of an organ. This study aimed to explore the efficiency and safety of remote ischemic conditioning in patients with acute ischemic stroke. We hypothesized that remote ischemic conditioning administered from the first day of hospital admission would improve the infarct volume and clinical outcome at 180 days.Material and Methods: We performed a unicentric double-blind randomized controlled trial. We included all patients consecutively admitted to an Emergency Neurology Department with acute ischemic stroke, ineligible for reperfusion treatment, up to 24 hours from onset. All subjects were assigned to receive secondary stroke prevention treatment along with remote ischemic conditioning on the non-paretic upper limb during the first 5 days of hospitalization, twice daily - a blood pressure cuff placed around the arm was inflated to 20 mmHg above the systolic blood pressure (up to 180 mmHg) in the experimental group and 30 mmHg in the sham group. The primary outcome was the difference in infarct volume (measured on brain CT scan) at 180 days compared to baseline, whereas the secondary outcomes included differences in clinical scores (NIHSS, mRS, IADL, ADL) and cognitive/mood changes (MoCA, PHQ-9) at 180 days compared to baseline.Results: We enrolled 40 patients; the mean age was 65 years and 60% were men. Subjects in the interventional group had slightly better recovery in terms of disability, as demonstrated by the differences in disability scores between admission and 6 months (e.g., the median difference score for Barthel was −10 in the sham group and −17.5 in the interventional group, for ADL −2 in the sham group and −2.5 in the interventional group), as well as cognitive performance (the median difference score for MoCA was −2 in the sham group and −3 in the interventional group), but none of these differences reached statistical significance. The severity of symptoms (median difference score for NIHSS = 5 for both groups) and depression rate (median difference score for PHQ-9 = 0 for both groups) were similar in the two groups. The median difference between baseline infarct volume and final infarct volume at 6 months was slightly larger in the sham group compared to the interventional group (p = 0.4), probably due to an initial larger infarct volume in the former.Conclusion: Our results suggest that remote ischemic conditioning might improve disability and cognition. The difference between baseline infarct volume and final infarct volume at 180 days was slightly larger in the sham group.

Measurement of disability among people with severe mental disorders - pilot study to examine environmental impacts on mental health outcomes in Ghana

Background/aim: Mental Disorders are a leading cause of morbidity and suicide globally; around 2.15 million people live with mental disabilities in Ghana. While neurotoxic impacts of air pollution have been reported, little is known about effects on mental health outcomes. Possible impacts of household fossil fuel air pollution and mental disorders are largely unknown. In this exploratory study, we assessed participants’ level of self-reported disability and explore differences in disability scores by important sociodemographic/environmental characteristics. Methods: This pilot study was conducted among patients living with severe mental disorders in the Kintampo North Municipality and Kintampo South District of Ghana. The 12-item validated WHO Disability Assessment Schedule (WHODAS) 2.0 was used to measure participant’s level of functional disability. Descriptive statistics were calculated for all outcomes and patient characteristics. Household primary cookstove and fuel use for cooking or heating were assessed. We examined WHODAS scores by several characteristics, including gender, employment and marital status.Results: There were 70 participants who completed the survey within the pilot study period. The mean age was 38 years; the majority of participants were male (57%; 40/70). Most (31%; 22/70) of the study participants had Junior High/Middle School education, have never been married (57%; 40/70) and were not currently employed (83%; 58/70). More than half of the study participants (57%; 40/70) were living independently in their communities compared to 43% who needed assistance from family members. Overall, participants reported elevated WHODAS scores indicating their inability to function well on daily basis due to their mental disorder. About 93% (65/70) participants used traditional cookstove (3-stone fires) for cooking, with wood as the primary fuel. Conclusion: This pilot study provides preliminary findings to further explore environmental exposures, particularly household air pollution in relation to mental health outcomes and severity in a mixed-method study in Ghana.

Psychosocial and Demographic Characteristics of Children and Adolescents With Headache Presenting for Treatment in a Headache Infusion Center.

Approximately 10% of pediatric patients have recurrent headaches, with migraine being the most common headache type. If untreated, migraine may progress to status migrainosus, a debilitating condition of prolonged duration, high pain severity, and significant disability. There is high variability in the treatment of status migrainosus including medications used and treatment setting, which may occur in the emergency room, as an inpatient admission, or, less often, in an outpatient infusion center. The paucity of research on the treatment of status migrainosus is a limitation to treatment effectiveness. The objective of the study was twofold. First, we sought to examine the demographic characteristics of children and adolescents accessing our outpatient infusion center for prolonged headache. Second, we sought to determine whether any demographic or psychosocial differences exist between patients who access infusion therapy compared to patients who do not access infusion therapy for their headaches. We conducted a retrospective chart review of all patients between the ages of 6 and 19years who were treated in our outpatient headache infusion center. A subset of these patients completed a behavioral health evaluation (treatment group) and they were compared to a control group of similar age (birthdate within 6months) and gender to patients not seeking infusion treatment. Variables of interest included patient demographics, headache type and characteristics, and scores on the Pediatric Quality of Life Inventory (PedsQL), Functional Disability Inventory (FDI), Pediatric Pain Coping Inventory (PPCI), and the Behavior Assessment System for Children - Second Edition (BASC-2). A total of 284 patients were included in the study (n=227 receiving infusion treatment and n=57 controls). Patients were primarily female (224/286; 78.9%), Caucasian (254/286; 90.1%), and had a mean age of 15years. Findings suggest a promising difference in the PPCI Distraction subscale, χ2 (1)=3.7, P=.054, with a mean rank score of 61.90 for the treatment group and 50.21 for the control group. Additionally, a statistically significant difference was noted on the Social Support subscale, χ2 (1)=10.6, P=.001, with a mean rank score of 65.92 for the treatment group and 46.26 for the control group. Results also indicated a statistically significant difference in disability scores, χ2 (1)=10.0, P=.002, with a mean rank FDI score of 66.83 for the treatment group and 47.34 for the control group. Patients in the infusion group also reported lower quality of life on the PedsQL Total score (F[1, 109]=5.0, P=.028; partial η2 =0.044), and on the Physical (F[1, 109]=7.9, P=.006; partial η2 =0.069) and School (F[1, 109]=4.6, P=.035; partial η2 =0.041) subscales. No significant differences were found on the BASC-2. Parent reported data also revealed a significantly higher level of disability among patients seeking infusion treatment compared to the non-infusion group χ2 (1)=11.7, P=.001. However, there were no significant differences on the PedsQL, PPCI, or BASC-2. Our findings support the disabling nature of migraine among children and adolescents, with higher levels of disability and lower quality of life reported in the group of patients utilizing infusion treatment. Developing concrete treatment plans and goals combined with bio-behavioral therapy are necessary to reduce functional disability and increase quality of life among these patients. Awareness of this patient group's pain-related coping strategies may help healthcare providers tailor treatment recommendations and develop or refine cognitive-behavioral headache treatment techniques.

Comparison of Custom-made Versus Prefabricated Thumb Splinting for Carpometacarpal Arthrosis: A Systematic Review and Meta-analysis.

The goal of this study was to compare the two types of orthoses, prefabricated soft splints versus short thermoplastic custom-made splints, that are the most commonly used for the management of first carpometacarpal (CMC) osteoarthritis (OA). We conducted a meta-analysis and systematic review in the literature based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We extracted the outcomes of disability scores, pain scores, grip and pinch strength and gathered the unified data accordingly. We included five randomized clinical trials with 230 patients with the mean age of 61 years and the mean follow-up of 8.1 weeks. The results of the pooled data demonstrated only a statistically significant difference in disability scores among splints in favor of the prefabricated splints. The rest of the outcome measures consisting of pain, grip strength, and pinch strength were not statistically different. According to our systematic review and meta-analysis, both thumb-based splints improved pain and function in the first CMC OA in a short-term follow-up, nevertheless the efficacy of prefabricated splints in abatement of disability scores was significantly higher than custom-made splints. In contrast, the other outcome measures including pain, grip and pinch strength were improved identically after wearing either of the splints. II.

P556 Female Crohn's disease patients and ulcerative colitis patients on biologic therapy are most disabled

Background: There is limited disability data in the biologic era using Patient Reported Outcomes. The aims of this study were to describe the disability status and identify determinants of disability in a well characterized cohort of IBD patients using the Inflammatory Bowel Disease Disability Index (IBD-DI). Methods: From June 2015 to September 2016, the IBD-DI was administered to adult IBD patients. Natural history data were available for each patient from time of diagnosis to time of completing the questionnaires. Clinical remission status at time of answering the questionnaire was also recorded. Results: 250 patients with IBD completed the IBD-DI. The median duration from diagnosis to completion of questionnaire was 45 months. The median age at diagnosis was 30 years. The median IBD-DI was 31.3 (IQR 17.9–41.1). The median IBD-DI score for CD was 32.14 (IQR 19.2–45.1) in CD and 28.71 (IQR 17.4–44.5) in UC. CD females were more disabled than males (IBD-DI score 36.6 vs 27.1, p=0.001). There was no significant gender bias in the UC group (female IBD-DI score 32.6 vs male 30.6, p=NS). Patients with active disease at the time of answering the questionnaires had a higher IBD-DI score compared with patients in remission (42.4 vs 29.0, p<0.001). Disease phenotype or disease location did not influence the IBD-DI score in CD or UC. Female CD patients in remission were also more disabled compared with male CD patients (33.9 vs 23.9, p=0.002). There was no difference in disability scores by gender in the UC group adjusted for clinical activity. UC patients on biologic therapy were more disabled than those who were not, despite being in clinical remission (IBD-DI score 36.7 vs 25.9, p=0.03). CD patients who had undergone intestinal resection demonstrated a trend towards reduced disability compared to those who had not (IBD-DI score 30.5 vs 35.3, p=0.059). CD patients with perianal disease were not more disabled than those without, (IBD-DI score 34.0 vs 32.0, p=0.3). 52 patients were severely disabled (IBD-DI score >50). 62% had CD, 71% were female, and 46% were in clinical remission at the time of answering the questionnaires. Of the CD patients, 70% had an inflammatory phenotype, 15% had perianal disease, and only 31% had prior intestinal resection. Only 10% of the UC patients with severe disability had undergone colectomy for refractory disease. Factors associated with high disability scores on multivariate analysis were female gender (p=0.01) and active disease (p=0.001) in CD, and need for biologic therapy (p=0.027) and active disease (p=0.005) in UC. Conclusions: Female CD patients are more disabled than males. The need for biologic therapy in UC is associated with higher disability. Severe disability is present in the absence of clinical activity.

Clinical associations, biological risk factors and outcomes of cerebral venous sinus thrombosis.

ObjectiveCerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disease affecting young adults. The majority of the patients are female. The aim of this study is to assess the clinical associations, risk factors and outcomes of the patients with CVST.MethodsThe data of 75 patients with CVST admitted to our hospital between 2006 and 2016 were reviewed. Demographic and clinical features and the thrombophilic risk factors of the patients were recorded. The localizations of the thrombi were determined and modified Rankin score at the time of onset and discharge were calculated.ResultsThe majority of our patients (78.7%) were female. Median age was 35 years (16–76). The most common symptom was headache (86.7%). In 82.6% of our patients, inherited or acquired risk factors for thrombosis were detected. Transverse sinus was the most common site of thrombosis followed by sigmoid and superior sagittal sinuses. Two thirds of the patients had involvement of multiple sinuses. The patients with the involvement of sagittal sinus had better disability at the time of admittance (p = 0.013) while the number of involved sinuses was correlated worse disability (p = 0.015). The neurologic states in the majority of the patients were improved by the end of the hospitalization period (p = 0.001). There was no significant difference in disability score at discharge between men and women (p = 0.080). No patient with CVST died in the hospitalization period.ConclusionsThis study is one of the largest cohort studies on CVST in our region. The results of the study disclosed that CVST had wide range of clinical manifestations and non-specific symptoms at the beginning. For that reason, in especially high risk groups for thrombosis, the diagnosis of CVST should be kept in mind.

Change in pain, disability and influence of fear-avoidance in a work-focused intervention on neck and back pain: a randomized controlled trial.

BackgroundNeck and back pain are among the most common causes of prolonged disability, and development of interventions with effect on pain, disability and return to work is important. Reduction of fear avoidance might be one mechanism behind improvement after interventions. The aim of the present study was to evaluate changes in pain and disability at the 12-month follow-up of patients with neck and back pain treated with a work-focused intervention compared to patients treated with standard interventions, and the influence of improvement fear avoidance beliefs during the interventions on pain, disability and return to work at 12-month follow-up.Methods413 employed patients with back or neck pain referred to secondary care, and sick-listed between 4 weeks and 12 months, were randomized to a work-focused rehabilitation or control interventions. Follow-up was conducted 4 and 12 months after inclusion. The groups were compared (independent sample t-test) regarding differences in disability scores (Oswestry disability index/neck disability index) and pain (numeric rating scale) from baseline to 12-month follow-up. Changes in fear avoidance beliefs (FABQ) from baseline to 4 month follow-up were calculated, and the association between this change and return to work, pain and disability at 12 months were tested in stepwise multiple logistic regression models.ResultsPain and, disability scores decreased to in both the work-focused and control intervention to 12-month follow-up, and there were no significant differences between the groups. FABQ decreased similarly in both groups to 4 month follow-up. The logistic regression model revealed an association between a reduced FABQ work score at 4 months and return to work within one year (adjusted OR 3.60, 95% CI 1.19 to 10.88). Reduced FABQ physical activity score at 4 months was associated with decreased disability after 12 months (adjusted OR (3.65. 95% CI 1.43 to 9.28).ConclusionsShort work-focused rehabilitation had the same effect on pain and disability as control interventions. Reduction in FABQ-W score after treatment seems to be an important predictor for return to work in both groups.Trial registrationClinicaltrials.gov NCT00840697

8.: Comparison of switch to fingolimod or interferon beta/glatiramer acetate as second line therapy in active multiple sclerosis

This study aimed to compare the effectiveness of fingolimod with interferon beta or glatiramer acetate (IFN/GA) as second line agents in reducing relapse rates, accumulation of disability and increasing treatment persistence in active multiple sclerosis. Data was extracted from MSBase, an international multiple sclerosis patient registry. Patients were identified who had failed first line therapy with IFN/GA and had switched to either fingolimod or another IFN/GA preparation. Propensity score matching was used to match patients in each treatment arm by baseline clinical and demographic characteristics. Paired Cox proportional hazards models was used to evaluate differences in time to first relapse and time to treatment discontinuation between the two groups. Paired t-tests were used to estimate differences in relapse frequency and change in disability. There were 692 patients switching to IFN/GA and 206 switching to fingolimod who were eligible for inclusion. The matching procedure identified 477 and 149 closely matched patients in the respective groups who were used for outcomes analyses. Follow-up was censored at 18 months post-switch (median 11 months). Patients switching to fingolimod had a lower hazard of relapse (hazard ratio 0.50, 95% confidence interval [CI] 0.39–0.64) and lower annualised relapse rates (0.31 versus 0.59, p = 0.01) compared to IFN/GA. There was no difference in disability scores between groups. The fingolimod group also had a lower hazard of treatment discontinuation (hazard ratio 0.39, 95%CI 0.28–0.53) compared to IFN/GA. Following an on-treatment relapse with IFN/GA, switching to fingolimod is associated with lower hazard of relapse and increased treatment persistence compared with switching to another IFN/GA.

Characterization of early onset neurofibromatosis type 2

Neurofibromatosis type 2 (NF2) is an autosomal dominant multiple neoplasia syndrome of the central nervous system. The aim of the present study was to characterize the clinical course of early onset NF2. The specific Japanese disease registry for NF2 in 2010 was analyzed retrospectively. The male:female ratio for the 312 patients identified in the database was 1:1.29. The median age at onset was 25years (range 2–76years), with 31.3% of patients exhibiting symptoms at <20years of age. Patients with an age at onset of <20years were found to have more frequent spinal cord and extravestibular cranial nerve involvement, cutaneous signs, and convulsions than patients with a later age at onset. Of patients younger than 18years of age, half did not exhibit hearing problems; in contrast, they frequently had other cranial nerve schwannomas, cranial meningioma, spinal cord tumors, and subcutaneous schwannoma. There were weak but significant positive correlations between symptomatic periods and disability scores in patients with an age of onset of ⩾20years (R=0.225; P<0.01) and those with an earlier age of onset (R=0.306; P<0.01). Although there were no significant differences in disability scores between genders or patients with an age at onset of <20 versus ⩾20years, patients with an earlier age at onset had significantly higher disability scores for spinal symptoms than patients with an age at onset of ⩾20years. Atypical extravestibular presentation is common in early onset NF2, with more prominent spinal symptoms.

Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: a 10/66 Dementia Research Group population-based survey

SummaryBackgroundDisability in elderly people in countries with low and middle incomes is little studied; according to Global Burden of Disease estimates, visual impairment is the leading contributor to years lived with disability in this population. We aimed to assess the contribution of physical, mental, and cognitive chronic diseases to disability, and the extent to which sociodemographic and health characteristics account for geographical variation in disability.MethodsWe undertook cross-sectional surveys of residents aged older than 65 years (n=15 022) in 11 sites in seven countries with low and middle incomes (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Disability was assessed with the 12-item WHO disability assessment schedule 2.0. Dementia, depression, hypertension, and chronic obstructive pulmonary disease were ascertained by clinical assessment; diabetes, stroke, and heart disease by self-reported diagnosis; and sensory, gastrointestinal, skin, limb, and arthritic disorders by self-reported impairment. Independent contributions to disability scores were assessed by zero-inflated negative binomial regression and Poisson regression to generate population-attributable prevalence fractions (PAPF).FindingsIn regions other than rural India and Venezuela, dementia made the largest contribution to disability (median PAPF 25·1% [IQR 19·2–43·6]). Other substantial contributors were stroke (11·4% [1·8–21·4]), limb impairment (10·5% [5·7–33·8]), arthritis (9·9% [3·2–34·8]), depression (8·3% [0·5–23·0]), eyesight problems (6·8% [1·7–17·6]), and gastrointestinal impairments (6·5% [0·3–23·1]). Associations with chronic diseases accounted for around two-thirds of prevalent disability. When zero inflation was taken into account, between-site differences in disability scores were largely attributable to compositional differences in health and sociodemographic characteristics.InterpretationOn the basis of empirical research, dementia, not blindness, is overwhelmingly the most important independent contributor to disability for elderly people in countries with low and middle incomes. Chronic diseases of the brain and mind deserve increased prioritisation. Besides disability, they lead to dependency and present stressful, complex, long-term challenges to carers. Societal costs are enormous.FundingWellcome Trust; WHO; US Alzheimer's Association; Fondo Nacional de Ciencia Y Tecnologia, Consejo de Desarrollo Cientifico Y Humanistico, Universidad Central de Venezuela.

Regular Vigorous Physical Activity and Disability Development in Healthy Overweight and Normal-Weight Seniors: A 13-Year Study

We examined the relationship of regular exercise and body weight to disability among healthy seniors. We assessed body mass index (BMI) and vigorous exercise yearly (1989-2002) in 805 participants aged 50 to 72 years at enrollment. We studied 4 groups: normal-weight active (BMI< 25 kg/m(2); exercise> 60 min/wk); normal-weight inactive (exercise<or= 60 min/wk); overweight active (BMI>or= 25 kg/m(2)); and overweight inactive. Disability was measured with the Health Assessment Questionnaire (0-3; 0= no difficulty, 3= unable to do). We used multivariable analysis of covariance to determine group differences in disability scores after adjustment for determinants of disability. The cohort was 72% men and 96% White, with a mean age of 65.2 years. After 13 years, overweight active participants had significantly less disability than did overweight inactive (0.14 vs 0.19; P= .001) and normal-weight inactive (0.22; P= .03) participants. Similar differences were found between normal-weight active (0.11) and normal-weight inactive participants (P< .001). Being physically active mitigated development of disability in these seniors, largely independent of BMI. Public health efforts that promote physically active lifestyles among seniors may be more successful than those that emphasize body weight in the prevention of functional decline.

Surgery versus Prolonged Conservative Treatment for Sciatica

Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known. We randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual-analogue scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups. Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients designated for conservative treatment, 55 (39%) were treated surgically after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (P=0.13). Relief of leg pain was faster for patients assigned to early surgery (P<0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72 to 2.22; P<0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%. The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. (Current Controlled Trials number, ISRCTN26872154 [controlled-trials.com].).

Systematic Review of Randomized Trials Comparing Lumbar Fusion Surgery to Nonoperative Care for Treatment of Chronic Back Pain

Systematic review of randomized trials comparing surgical to nonsurgical treatment of discogenic back pain. Compare research methods and results. Recent reports have increased debate about the role of surgery in the treatment of chronic back pain associated with lumbar disc degeneration. We conducted a systematic review of randomized trials comparing lumbar fusion surgery to nonsurgical treatment of chronic back pain associated with lumbar disc degeneration. A literature search identified 5 randomized trials that compared fusion to nonoperative treatment for chronic low back pain. Excluding 1 trial for spondylolisthesis, we compared study participants, interventions, analyses, and outcomes in 4 trials that focused on nonspecific chronic back. All trials enrolled similar subjects. One study suggested greater improvement in back-specific disability for fusion compared to unstructured nonoperative care at 2 years, but the trial did not report data according to intent-to-treat principles. Three trials suggested no substantial difference in disability scores at 1-year and 2-years when fusion was compared to a 3-week cognitive-behavior treatment addressing fears about back injury. However, 2 of these trials were underpowered to identify clinically important differences. The third trial had high rates of cross-over (>20% for each treatment) and loss to follow-up (20%); it is unclear how these affected results. Surgery may be more efficacious than unstructured nonsurgical care for chronic back pain but may not be more efficacious than structured cognitive-behavior therapy. Methodological limitations of the randomized trials prevent firm conclusions.

A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial

The aim of this study was to assess the long-term effect of a supervised fitness programme on patients with chronic low back pain. The design of the study was a single blind randomised controlled trial with follow-up, by postal questionnaire, 2 years after intervention. The Oswestry Low Back Pain Disability Index was used as the outcome measure to assess daily activity affected by back pain. Eighty-one patients with chronic low back pain, who were referred to the physiotherapy department of a National Health Service orthopaedic hospital, were randomised to either a supervised fitness programme or a control group. Patients in the intervention group and control group were taught specific exercises to be continued at home and referred to a backschool for back care education. In addition, the intervention group attended eight sessions of a supervised fitness programme. Sixty-two patients (76%) with a mean age of 37 years, returned the Oswestry Low Back Pain Disability Index questionnaire. Of these, 29 were in the intervention group and 31 in the control group. Patients in the intervention group demonstrated a mean reduction of 7.7% in the Oswestry Low Back Pain Disability Index score (95% confidence interval of mean paired difference 3.9, 11.6 P<0.001), compared with only 2.4% in the control group (95% confidence interval of mean paired difference −2.0, 6.9 P>0.05). Between group comparisons demonstrated a statistically significant difference in disability scores between the treatment and control group (mean difference 5.8, 95% confidence interval 0.3, 11.4 P<0.04). This study supports the current trend towards a more active treatment approach to low back pain. We have demonstrated clinical effectiveness of a fitness programme 2 years after treatment but this needs to be replicated in a larger study which should include a cost effectiveness analysis, further analysis of objective functional status and a placebo intervention group.