Bertrand Léger

Introduction: Health literacy (HL) is defined as the ability to access, understand, evaluate and apply health-related information, which can influence individuals’ health outcomes. Blue-collar workers, who often have lower educational attainment and experience language barriers, are at increased risk of limited HL. This systematic review aims to assess the prevalence of limited HL among blue-collar workers to inform the development of appropriate interventions for its improvement. Methods and analysis: The systematic review will assess the prevalence of limited HL among blue-collar workers. We will include all quantitative study designs using any instrument for measuring general HL. We will exclude studies that focus on specific types of HL and specific health conditions. We have performed a literature search from inception up to 30 April 2025, in the Medline, Embase, CINAHL, Web of Science and Cochrane Central Register of Controlled Trials (CENTRAL) databases. We will also search eligible articles from Google Scholar and Open Grey as sources of unpublished studies/gray literature. Two independent reviewers will conduct the primary screening of articles, data extraction and quality assessment (using the Cochrane risk-of-bias tool for randomised trials and risk of bias in non-randomised studies of exposure), with a third individual available to resolve conflicts. We will assess heterogeneity using the χ² test and I² test. If there is sufficient homogeneity, we will pool studies in a meta-analysis or summarise the findings narratively if heterogeneity is too high. We will use a random effects model for our analysis, and we will use funnel plots to evaluate potential publication bias. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to assess the certainty of findings. Ethics and dissemination: Ethical approval will not be required for this review as there is no primary data collection involving humans. The results will be published in a peer-reviewed journal and presented at relevant conferences. PROSPERO registration number: CRD42024597732.

Introduction: The effects of pain medication on physical performance in chronic pain are poorly understood. We examined the association between analgesics and physical performance in people with chronic musculoskeletal pain (CMSP) requiring rehabilitation. Methods: We classified participants into 3 categories according to the highest level of medication used at admission for rehabilitation: no analgesics (NAs), nonopioid analgesics (NOAs), and opioid analgesics (OPAs). We measured performance with functional tests (6-minute walk test [6MWT], progressive isoinertial lifting evaluation [PILE], steep ramp test, handgrip strength test [HST], 5 times sit-to-stand test, and 1-minute stair-climbing test [1MSCT]) at admission and discharge. Multiple regression models were used to assess the differences in functional capacity between the 3 groups, adjusting for potential confounders. Results: We included 4,339 individuals; 1,731 took no analgesics (40%), 1,742 took NOAs (40%), and 866 took OPAs (20%). The median consumption was 11.7 mg per day according to morphine-equivalent dose calculation. Physical performance was poorer for patients taking than those not taking analgesics in all tests examined. We found a negative gradient in performance with increasing WHO analgesic ladder. The odds of achieving clinically significant improvements in 4 tests (6MWT, PILE, HST affected side, and 1MSCT) was reduced for people taking opioids compared with the NA group. Conclusion: Given the inconclusive and limited evidence for the benefit of analgesics on pain and disability in CMSP, health professionals should be aware of these results for even low doses of opioids, which were associated with poor physical performance and rehabilitation progress.

AIMS: This exploratory study aimed to assess the changes in functional capacity and patient-reported outcome measures (PROMs) experienced by outpatients undergoing cardiac rehabilitation; and factors associated with health-related quality of life. METHODS: We prospectively included all consecutive patients diagnosed with various cardiac conditions who had undergone a 10-week multidisciplinary cardiac rehabilitation programme from October 2020 to October 2022. The primary outcomes were functional capacity, including the 6-minute walk test, maximal short-term exercise capacity, estimated metabolic equivalent of task (eMET) and maximal quadriceps isometric strength at entry and discharge; and PROMs including the Hospital Anxiety and Depression Scale (HADS), quality of life (HeartQoL), and level of work, sport and leisure physical activity (Baecke) at entry, discharge and at 6 months. Secondarily, we assessed factors associated with heart-related quality of life over the 6-month period using multi-level mixed-effects generalised linear models adjusted for age, sex and time point. RESULTS: Among the 273 included patients, 81% were men and the median age was 63 years (range: 57–69). From programme entry to discharge, median values significantly increased for the 6-minute walk test (+60 m, 95% CI: 50–65), maximal short-term exercise capacity (+50 W, 95% CI: 50–50), eMET (+0.9, 95% CI: 0.7–1.1), maximal left quadriceps isometric strength (+3 Nm, 95% CI: 2–4) and maximal right quadriceps isometric strength (+4 Nm, 95% CI: 2.4–4.7). The median scores of depression, anxiety, physical and emotional heart-related quality of life and leisure activity were significantly improved from entry to the 6-month follow-up. The physical domain of quality of life was associated with the 6-minute walk test (coefficient: 1.001, 95% CI: 1.00–1.001) and anxiety score (coefficient: 0.97, 95% CI: 0.96–0.99) while the emotional domain was associated with level of depression (coefficient: 0.95, 95% CI: 0.94–0.97) and anxiety (coefficient: 0.98, 95% CI: 0.97–0.99). CONCLUSIONS: Our study showed that functional capacity significantly improved at discharge from the cardiac rehabilitation programme, as did the symptoms of anxiety and depression, quality of life and leisure-time physical activity at 6 months. The 6-minute walk test and symptoms of depression or anxiety were found to be significantly associated with quality of life. A cardiac rehabilitation programme could be proposed to eligible cardiac patients to improve their outcomes.

Introduction: Opioid prescription is associated with various biopsychosocial (BPS) domains. Explaining how they interact is worth to better understand their role. Objectives: To assess direct and indirect effects of BPS complexity and pain-related factors on opioid prescription in patients with chronic musculoskeletal pain. Methods: We included 3,923 individuals admitted to a tertiary care rehabilitation clinic. Two outcomes were defined: likelihood of opioid prescription at admission (yes/no) and daily morphine equivalent dose (dMED) during rehabilitation. Predictors were sociodemographic factors, injury severity and location, pain-related factors (pain catastrophizing, depressive symptoms, pain severity), and BPS complexity assessed by the INTERMED method. Structural equation modelling was used to assess the direct and indirect effects of BPS complexity on outcomes. Results: Biopsychosocial complexity had a direct effect on opioid prescription (OR 1.20; 95% CI 1.10–1.32) and indirect effects via pain severity (OR 1.09; 95% CI 1.06–1.12) and depressive symptoms (OR 1.02; 95% CI 1.00–1.04). Biopsychosocial complexity also had direct effect on dMED (β = 1.17, 95% CI 1.06–1.28) and an indirect effect via pain severity (exp β = 1.03; 95% CI 1.00–1.07). Pain catastrophizing was indirectly associated with opioid prescription and dose via pain. The likelihood of opioid prescription was associated with female sex, increased education level, and spine trauma; the latter 2 factors were also associated with increased dMED. Conclusion: Our study suggests that BPS complexity is associated with opioid prescription and dose, with direct and indirect effects via pain severity or depressive symptoms. Screening and addressing patients' complexity may help decrease opioid prescriptions and risk of misuse.

People with chronic musculoskeletal pain (CMSP) often have low physical activity. Various factors can influence the activity level. The aim of this study was to monitor physical activity, assessed by the number of steps per day, over time in people with CMSP and identify factors that could be associated with this activity feature. This prospective study involved people undergoing rehabilitation following an orthopedic trauma that had led to CMSP. At entry, participants completed self-reported questionnaires assessing pain, anxiety, depression, catastrophyzing, kinesiophobia, and behavioural activity patterns (avoidance, pacing and overdoing). They also underwent functional tests, assessing walking endurance and physical fitness. To determine daily step counts, participants wore an accelerometer for 1 week during rehabilitation and 3 months post-rehabilitation. The number of steps per day was compared among three time points: weekend of rehabilitation (an estimate of pre-rehabilitation activity; T1), weekdays of rehabilitation (T2), and post-rehabilitation (T3). Linear regression models were used to analyze the association between daily steps at T2 and at T3 and self-reported and performance-based parameters. Data from 145 participants were analyzed. The mean number of steps was significantly higher during T2 than T1 and T3 (7323 [3047] vs. 4782 [2689], p < 0.001, Cohen’s d = 0.769, and 4757 [2680], p < 0.001, Cohen’s d = 0.693), whereas T1 and T3 results were similar (p = 0.92, Cohen’s d = 0.008). Correlations of number of steps per day among time points were low (r ≤ 0.4). Multivariable regression models revealed an association between daily steps at T2 and pain interfering with walking, anxiety and overdoing behaviour. Daily steps at T3 were associated with overdoing behaviour and physical fitness. Despite chronic pain, people in rehabilitation after an orthopedic trauma increased their physical activity if they were given incentives to do so. When these incentives disappeared, most people returned to their previous activity levels. A multimodal follow-up approach could include both therapeutic and environmental incentives to help maintain physical activity in this population.

BACKGROUND: Cortical excitation/inhibition dynamics have been suggested as a key mechanism occurring after stroke. Their supportive or maladaptive role in the course of recovery is still not completely understood. Here, we used transcranial magnetic stimulation (TMS)-electroencephalography coupling to study cortical reactivity and intracortical GABAergic inhibition, as well as their relationship to residual motor function and recovery longitudinally in patients with stroke. METHODS: Electroencephalography responses evoked by TMS applied to the ipsilesional motor cortex were acquired in patients with stroke with upper limb motor deficit in the acute (1 week), early (3 weeks), and late subacute (3 months) stages. Readouts of cortical reactivity, intracortical inhibition, and complexity of the evoked dynamics were drawn from TMS-evoked potentials induced by single-pulse and paired-pulse TMS (short-interval intracortical inhibition). Residual motor function was quantified through a detailed motor evaluation. RESULTS: From 76 patients enrolled, 66 were included (68.2±13.2 years old, 18 females), with a Fugl-Meyer score of the upper extremity of 46.8±19. The comparison with TMS-evoked potentials of healthy older revealed that most affected patients exhibited larger and simpler brain reactivity patterns ( P _cluster <0.05). Bayesian ANCOVA statistical evidence for a link between abnormally high motor cortical excitability and impairment level. A decrease in excitability in the following months was significantly correlated with better motor recovery in the whole cohort and the subgroup of recovering patients. Investigation of the intracortical GABAergic inhibitory system revealed the presence of beneficial disinhibition in the acute stage, followed by a normalization of inhibitory activity. This was supported by significant correlations between motor scores and the contrast of local mean field power and readouts of signal dynamics. CONCLUSIONS: The present results revealed an abnormal motor cortical reactivity in patients with stroke, which was driven by perturbations and longitudinal changes within the intracortical inhibition system. They support the view that disinhibition in the ipsilesional motor cortex during the first-week poststroke is beneficial and promotes neuronal plasticity and recovery.

Background: Most studies on stroke have been designed to examine one deficit in isolation; yet, survivors often have multiple deficits in different domains. While the mechanisms underlying multiple-domain deficits remain poorly understood, network-theoretical methods may open new avenues of understanding. Methods: Fifty subacute stroke patients (7±3days poststroke) underwent diffusion-weighted magnetic resonance imaging and a battery of clinical tests of motor and cognitive functions. We defined indices of impairment in strength, dexterity, and attention. We also computed imaging-based probabilistic tractography and whole-brain connectomes. To efficiently integrate inputs from different sources, brain networks rely on a rich-club of a few hub nodes. Lesions harm efficiency, particularly when they target the rich-club. Overlaying individual lesion masks onto the tractograms enabled us to split the connectomes into their affected and unaffected parts and associate them to impairment. Results: We computed efficiency of the unaffected connectome and found it was more strongly correlated to impairment in strength, dexterity, and attention than efficiency of the total connectome. The magnitude of the correlation between efficiency and impairment followed the order attention>dexterity ≈ strength (strength: | r |=.03, P =0.02, dexterity: | r |=.30, P =0.05, attention: | r |=.55, P <0.001). Network weights associated with the rich-club were more strongly correlated to efficiency than non-rich-club weights. Conclusions: Attentional impairment is more sensitive to disruption of coordinated networks between brain regions than motor impairment, which is sensitive to disruption of localized networks. Providing more accurate reflections of actually functioning parts of the network enables the incorporation of information about the impact of brain lesions on connectomics contributing to a better understanding of underlying stroke mechanisms.

Purpose: To assess and compare the healthcare costs, time to fitness for work (TFW) between chronic complex regional pain syndrome (CRPS) and non-CRPS; and identify factors associated with these outcomes in a comparative longitudinal study. Patients and Methods: 148 patients with chronic CRPS of the hand and 273 patients with chronic hand impairments but without CRPS (non-CRPS) were admitted at a Swiss rehabilitation clinic between 2007 and 2016. Healthcare costs and TFW were retrieved from insurance data over 5 years after the accident. Socio-demographic factors, biopsychosocial complexity measured by means of the INTERMED questionnaire, pain intensity and DASH disability scores were collected during rehabilitation. Generalized estimation equations and Cox proportional-hazards models were used to identify factors associated with outcomes. Results: Healthcare costs were increased by 20% for the CRPS versus non-CRPS group (coefficient = 1.20, 95% CI = 1.08-1.35, p<0.001). The median TFW was longer for CRPS than non-CRPS patients (816 vs 672 days, p = 0.02). After adjusting for covariates, TFW did not differ between the two groups (hazard ratio = 0.94, 95% CI = 0.73-1.21, p=0.61). For CRPS patients, higher healthcare costs were associated with severe or moderate initial injury, high INTERMED or DASH disability scores. Longer TFW were associated with severe initial injury, low educational level, no work contract, and high INTERMED or DASH disability scores. Conclusion: Overall, the healthcare costs were higher for CRPS than non-CRPS patients, but the TFW was comparable. We demonstrated also the significant associations of disability and biopsychosocial factors with the healthcare costs and TFW in CRPS patients.