Massage Research

QUESTIONS: How much of an effect do five common physiotherapy interventions need to have for patients with low back pain to perceive they are worth their cost, discomfort, risk, and incovenience? Are there any differences between the interventions? Do specific characteristics of people with low back pain predict the smallest important difference?

DESIGN: Cross-sectional, observational study. PARTICIPANTS: 77 patients with non-specific low back pain who had not yet commenced physiotherapy intervention.

OUTCOME MEASURES: The smallest worthwhile effect was measured in terms of global perceived change (0 to 4) and percentage perceived change.

RESULTS: Participants perceived that intervention would have to make them ‘much better’, which corresponded to 1.7 (SD 0.7) on the 4-point scale, or improve their symptoms by 42% (SD 23), to make it worthwhile. There was little distinction made between interventions, regardless of whether smallest worthwhile effects were quantified as global perceived change (p = 0.09) or percentage perceived change (p = 1.00). Severity of symptoms independently (p = 0.01) predicted percentage perceived change explaining 9% of the variance, so that for each increase in severity of symptoms of 1 point out of 10 there was an increase of 4% in the percentage perceived change that participants considered would make intervention worthwhile.

CONCLUSIONS: Typically people with low back pain feel that physiotherapy intervention must reduce their symptoms by 42%, or make them feel ‘much better’ for intervention to be worthwhile.

Manuela Ferreira is a Research Fellow in the University of Sydney’s Faculty of Health Sciences. The study was the first time in back pain that researchers decided to hear patients on what they considered to be the clinical significance of an intervention. Five different approaches were given to patients with lower back pain: usually used in physiotherapy, massage, heat, ultrasound, exercise and manual therapy.

For measuring the benefit, they used two scales, how much improvement in percentage they would expect to see or they would need to see to consider all that worthwhile.  The patients told the researchers that they needed to be on average 42% better which is a lot more than what previous research had thought.

Now when you look at trials of physiotherapy-type treatments for low back pain compared to placebo or nothing then some of them just scrape into that 42% reduction in symptoms which people needed to have for treatment to be worth the effort. But when you look at research comparing treatments to each other rather than controls then the between treatment of differences in benefit are far lower than the amount wished for by the people in Manuela Ferreira and her colleagues’ study.

It is telling us researchers that we might be measuring the wrong things or we might not be measuring symptom improvement the way we should, the interventions we are using now maybe need to be changed – this is really the consumer’s opinion. They really want to see more improvement than what they are probably seeing right now.

When you are comparing two interventions and you find something that is statistically significant, the clinical significance of that difference is a lot more important.

We know what kind of benefit patients with back pain need, their expectations or perceptions are under-estimated by clinicians and researchers.

The interview from RAdio national

Dr Manuela Ferreira is a Research Fellow in the University of Sydney’s Faculty of Health Sciences.

Manuela Ferreira: It all started when I was doing my PhD and I had to go through a lot of clinical trials and when you read studies of clinical trials you read the results and it’s easy to see whether or not the difference between two groups or if the results of a paper are statistically significant. But I wanted to know if they were clinically significant.

Norman Swan: In other words it mattered to the researchers but did it matter to the consumer?

Manuela Ferreira: Exactly, it does matter to the consumer. There is actually literature and there are studies trying to estimate what we should call the clinical significance of results in clinical trials but it’s usually decided by researchers and clinicians but never by patients. So we thought we should hear patients.

Norman Swan: It’s a bit radical.

Manuela Ferreira: It was actually the first time in back pain that researchers decided to hear patients on what they considered to be the clinical significance of an intervention. So it was a bit radical but I still think it’s the way to go.

Norman Swan: So the questions you asked were geared towards how much of a benefit do you need to get for this to matter, for this to be worth the effort?

Manuela Ferreira: Exactly, we presented scenarios to patients related to low back pain interventions.

Norman Swan: Imaginary or real ones?

Manuela Ferreira: They were evidence based but we told them the risks, the inconvenience and a little bit of the benefits. I say a little bit because they were supposed to say how much benefit they were expecting and costs involved with the interventions and we asked patients how much improvement of their symptoms they needed to see to consider all that worthwhile.

Norman Swan: So you gave them doing nothing, having physiotherapy, having manipulation, maybe even having surgery or something like that.

Manuela Ferreira: Exactly, five different approaches usually used in physiotherapy, massage, heat, ultrasound, exercise and manual therapy.

Norman Swan: What sort of metric did you give them for measuring the benefit? I mean if you asked me I’m not sure I would know how to measure the benefit?

Manuela Ferreira: Yes, we used two scales, we asked them how much improvement in percentage they would expect to see or they would need to see to consider all that worthwhile.

Norman Swan: Just in their own terms accrued percentage?

Manuela Ferreira: Yes, from zero to 100% and the other one we gave them actually termed a little better, a lot better, much better, 100% better.

Norman Swan: Is this just the pain and movement or both?

Manuela Ferreira: It was symptoms. We are now doing a follow-up study and we are asking similar questions but concerning pain and disability and time to recover.

Norman Swan: So what did they tell you?

Manuela Ferreira: They told me that they needed to be on average 42% better which is a lot more than what previous research had thought.

Norman Swan: Now when you look at trials of physiotherapy-type treatments for low back pain compared to placebo or nothing then some of them just scrape into that 42% reduction in symptoms which people needed to have for treatment to be worth the effort. But when you look at research comparing treatments to each other rather than controls then the between treatment of differences in benefit are far lower than the amount wished for by the people in Manuela Ferreira and her colleagues’ study. So where does all that leave those of us who might have a sore back right now and are wondering what we might do about it?

Manuela Ferreira: This survey is just telling us how much they need to see to consider.

Norman Swan: This is placing the bar?

Manuela Ferreira: Exactly, so it’s something that is telling us researchers that we might be measuring the wrong things or we might not be measuring symptom improvement the way we should, the interventions we are using now maybe need to be changed – this is really the consumer’s opinion. They really want to see more improvement than what they are probably seeing right now.

Norman Swan: And we’ve just heard Rob Herbert’s, who is one of your colleagues, trial results using Health Report listeners on stretching where the effect was really tiny of stretching on preventing injury and soreness that when you’re comparing things if the margin is going to be that small it’s not worth it – people are going to say it’s not worth it.

Manuela Ferreira: Exactly, that’s the whole point. When you are comparing two interventions and you find something that is statistically significant, the clinical significance of that difference is a lot more important.

Norman Swan: Did the measure change if it was a cheap intervention for low back pain with no risk? In other words like stretching for example, while if it takes up 10 minutes of my day and I’m happy to do it, why shouldn’t I do it versus something that might actually cost you a fair bit of money and have risk attached to it? Did that change the percentage, I’d accept less benefit for that intervention?

Manuela Ferreira: There’s no difference, we compared five approaches, five interventions and there was no difference in the estimate among the five approaches. The study that we are conducting now we are comparing anti-flammatory pills and physiotherapy so these are very different interventions and they involve different costs and inconvenience and maybe risks, so we might be able to answer that question when we have the results of that one.

Norman Swan: So the bottom line then is that this could help people make decisions about their health care?

Manuela Ferreira: Exactly.

Norman Swan: Because you kind of know what benefit you’re going to get and whether it’s worth it.

Manuela Ferreira: Exactly, and we know what kind of benefit patients with back pain need, their expectations or perceptions are under-estimated by clinicians and researchers.

Norman Swan: So they’ve got to feel much better?

Manuela Ferreira: Yes they need to feel much better.

Norman Swan: Manuela Ferreira is a Research Fellow in the University of Sydney’s Faculty of Health Sciences.

Блок 50:
Статья с ID: 52
Заголовок статьи: Plant Foods For Preserving Muscle Mass
Контент:

Fruits and vegetables contain essential vitamins, minerals and fiber that are key to good health. Now, a newly released study by Agricultural Research Service (ARS)-funded scientists suggests plant foods also may help preserve muscle mass in older men and women.

The study was led by physician and nutrition specialist Bess Dawson-Hughes at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University in Boston, Mass.

The typical American diet is rich in protein, cereal grains and other acid-producing foods. In general, such diets generate tiny amounts of acid each day. With aging, a mild but slowly increasing metabolic “acidosis” develops, according to the researchers.

Acidosis appears to trigger a muscle-wasting response. So the researchers looked at links between measures of lean body mass and diets relatively high in potassium-rich, alkaline-residue producing fruits and vegetables. Such diets could help neutralize acidosis. Foods can be considered alkaline or acidic based on the residues they produce in the body, rather than whether they are alkaline or acidic themselves. For example, acidic grapefruits are metabolized to alkaline residues.

The researchers conducted a cross-sectional analysis on a subset of nearly 400 male and female volunteers aged 65 or older who had completed a three-year osteoporosis intervention trial. The volunteers’ physical activity, height and weight, and percentage of lean body mass were measured at the start of the study and at three years. Their urinary potassium was measured at the start of the study, and their dietary data was collected at 18 months.

Based on regression models, volunteers whose diets were rich in potassium could expect to have 3.6 more pounds of lean tissue mass than volunteers with half the higher potassium intake. That almost offsets the 4.4 pounds of lean tissue that is typically lost in a decade in healthy men and women aged 65 and above, according to authors.

Sarcopenia, or loss of muscle mass, can lead to falls due to weakened leg muscles. The authors encourage future studies that look into the effects of increasing overall intake of foods that metabolize to alkaline residues on muscle mass and functionality.

The study was published in the March issue of the American Journal of Clinical Nutrition.

US Department of Agriculture (2008, May 31). Plant Foods For Preserving Muscle Mass.