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Pottkotter K, Hazlett M, Mansfield CJ, Rethman K, Fritz JM, Quatman-Yates CC, Briggs MS. Understanding social determinants of health and physical therapy outcomes in patients with low back pain: A scoping review. Musculoskeletal Care 2024; 22:e1888. [PMID: 38747557 DOI: 10.1002/msc.1888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/10/2024] [Accepted: 04/13/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Low back pain (LBP) is the number one cause of disability worldwide; however, it is not clear how social determinants of health (SDOH) impact care management and outcomes related to physical therapy (PT) services for patients with LBP. OBJECTIVE The purposes of this scoping review are to examine and assimilate the literature on how SDOH and PT care relate to non-specific LBP outcomes and identify gaps in the literature to target for future research. METHODS Data were extracted from eight electronic databases from January 2011 to February 2022. Reviewers independently screened all studies using the PRISMA extension for scoping review guidelines. Data related to study design, type of PT, type of non-specific LBP, patient demographics, PT intervention, SDOH, and PT outcomes were extracted from the articles. RESULTS A total of 30,523 studies were screened, with 1961 articles undergoing full text review. Ultimately, 76 articles were identified for inclusion. Sex and age were the most frequent SDOH examined (88% and 78% respectively) followed by education level (18%). Approximately half of the studies that examined age, sex, and education level identified no effect on outcomes. The number of studies examining other factors was small and the types of outcomes evaluated were variable, which limited the ability to pool results. CONCLUSIONS Sex and age were the most frequent SDOH examined followed by education level. Other factors were evaluated less frequently, making it difficult to draw conclusions. Study design and heterogeneity of determinants and outcomes were barriers to examining the potential impact on patients with LBP.
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Affiliation(s)
- Kristy Pottkotter
- The Ohio State University Wexner Medical Center, Ambulatory Rehabilitation, Columbus, Ohio, USA
- The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, Columbus, Ohio, USA
| | - Miriam Hazlett
- The Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio, USA
| | - Cody J Mansfield
- The Ohio State University Wexner Medical Center, Ambulatory Rehabilitation, Columbus, Ohio, USA
- The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, Columbus, Ohio, USA
- The Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio, USA
| | - Katherine Rethman
- The Ohio State University Wexner Medical Center, Ambulatory Rehabilitation, Columbus, Ohio, USA
- The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, Columbus, Ohio, USA
| | - Julie M Fritz
- College of Health, The University of Utah, Salt Lake City, Utah, USA
| | - Catherine C Quatman-Yates
- The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, Columbus, Ohio, USA
- The Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio, USA
| | - Matthew S Briggs
- The Ohio State University Wexner Medical Center, Ambulatory Rehabilitation, Columbus, Ohio, USA
- The Ohio State University Wexner Medical Center, Sports Medicine Research Institute, Columbus, Ohio, USA
- The Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio, USA
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
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Bisby MA, Chandra SS, Dudeney J, Scott AJ, Titov N, Dear BF. Can Internet-Delivered Pain Management Programs Reduce Psychological Distress in Chronic Pain? Exploring Relationships Between Anxiety and Depression, Pain Intensity, and Disability. PAIN MEDICINE 2022; 24:538-546. [PMID: 36315066 DOI: 10.1093/pm/pnac158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 09/29/2022] [Accepted: 10/16/2022] [Indexed: 11/18/2022]
Abstract
Abstract
Background
Adults with chronic pain who also report high pain intensity and disability are more likely to experience depression and anxiety symptoms. The present study examined changes in anxiety and depression symptoms after an Internet-delivered pain management program based on baseline pain intensity and disability severity categories.
Methods
We conducted a secondary analysis of data from four randomized controlled trials (N = 1,333).
Results
Greater pain intensity and disability were associated with increased odds of elevated anxiety or depression symptoms at baseline. Treatment led to greater reductions in anxiety and depression symptoms compared with a waitlist control, and these improvements occurred irrespective of baseline pain intensity or disability severity. Those individuals who reported ≥30% improvements in pain intensity or disability after treatment were more likely to also report ≥30% improvements in psychological symptoms. Importantly, most participants who achieved ≥30% improvements in depression and anxiety had not experienced such improvements in pain intensity or disability.
Conclusion
These findings suggest that emerging Internet-delivered pain management programs can lead to reductions in psychological distress even when pain intensity and disability are severe or do not improve with treatment. This indicates the value of such treatments in treating distress and improving mental health in people with chronic pain.
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Affiliation(s)
- Madelyne A Bisby
- eCentreClinic, School of Psychological Sciences, Macquarie University , Sydney, Australia
| | - Shianika S Chandra
- eCentreClinic, School of Psychological Sciences, Macquarie University , Sydney, Australia
| | - Joanne Dudeney
- eCentreClinic, School of Psychological Sciences, Macquarie University , Sydney, Australia
| | - Amelia J Scott
- eCentreClinic, School of Psychological Sciences, Macquarie University , Sydney, Australia
| | - Nickolai Titov
- eCentreClinic, School of Psychological Sciences, Macquarie University , Sydney, Australia
| | - Blake F Dear
- eCentreClinic, School of Psychological Sciences, Macquarie University , Sydney, Australia
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Moitra E, Stein MD, Busch AM, Pinkston MM, Abrantes AM, Baker JV, Weisberg RB, Anderson BJ, Uebelacker LA. Acceptance of chronic pain in depressed patients with HIV: correlations with activity, functioning, and emotional distress. AIDS Care 2022; 34:1338-1346. [PMID: 34554879 PMCID: PMC8940733 DOI: 10.1080/09540121.2021.1981819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 09/09/2021] [Indexed: 01/26/2023]
Abstract
Chronic pain is highly prevalent among persons with HIV (PWH), as is depression. Both comorbidities might contribute to, as well as be maintained by, avoidance-based coping. A promising alternative to avoidance-based coping is acceptance. Acceptance of pain is associated with improved functioning and quality of life in chronic pain patients, but this relationship has not been substantially explored among PWH. Cross-sectional data from 187 adult outpatients enrolled in a randomized trial for depressed PWH with chronic pain were analyzed. Controlling for pain severity and demographics, the relationships among pain acceptance and indicators of activity, functioning, and emotional distress (i.e., anxiety and anger) were assessed in seven regression models. No significant relationships were found between self-reported physical activity or objective measurement of mean steps/day with pain acceptance. Results revealed an inverse relationship between chronic pain acceptance and pain-related functional interference (by.x = -.52, p < .01) and a positive relationship with self-reported functioning (by.x = 7.80, p < .01). A significant inverse relationship with anxiety symptoms (by.x = -1.79, p < .01) and pain acceptance was also found. Acceptance of chronic pain can facilitate decreased emotional distress, improved well-being, and better functioning and quality of life. Further investigation of chronic pain acceptance among PWH could inform the development of acceptance-based interventions.
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Affiliation(s)
- Ethan Moitra
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
| | - Michael D. Stein
- Behavioral Medicine and Addictions Research Unit, Butler Hospital, Providence RI, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston MA, USA
| | - Andrew M. Busch
- Department of Medicine, Hennepin Healthcare, Minneapolis MN, USA
- Department of Medicine, University of Minnesota - Twin Cities, Minneapolis MN, USA
| | - Megan M. Pinkston
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
- Lifespan Physicians Group, The Miriam Hospital, Providence RI, USA
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Ana M. Abrantes
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
- Behavioral Medicine and Addictions Research Unit, Butler Hospital, Providence RI, USA
| | - Jason V. Baker
- Department of Medicine, Hennepin Healthcare, Minneapolis MN, USA
- Department of Medicine, University of Minnesota - Twin Cities, Minneapolis MN, USA
| | - Risa B. Weisberg
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Bradley J. Anderson
- Behavioral Medicine and Addictions Research Unit, Butler Hospital, Providence RI, USA
| | - Lisa A. Uebelacker
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
- Psychosocial Research, Butler Hospital, Providence RI, USA
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Wong JJ, Tricco AC, Côté P, Liang CY, Lewis JA, Bouck Z, Rosella LC. Association Between Depressive Symptoms or Depression and Health Outcomes for Low Back Pain: a Systematic Review and Meta-analysis. J Gen Intern Med 2022; 37:1233-1246. [PMID: 34383230 PMCID: PMC8971223 DOI: 10.1007/s11606-021-07079-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Study results vary on whether depressive symptoms are associated with worse prognosis for low back pain (LBP). We assessed the association between depressive symptoms or depression and health outcomes in persons with LBP. METHODS We searched MEDLINE, Embase, CINAHL, and PsycINFO from inception to June 2020. Eligible studies were cohort and case-control studies assessing the association between depressive symptoms (questionnaires) or depression (diagnoses) and health outcomes in persons aged ≥16 years with LBP in the absence of major pathology. Reviewers independently screened articles, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. We classified exploratory versus confirmatory studies based on phases of prognostic factor investigation. We conducted random-effects meta-analyses and descriptive synthesis where appropriate. RESULTS Of 13,221 citations screened, we included 62 studies (63,326 participants; 61 exploratory studies, 1 confirmatory study). For acute LBP, depressive symptoms were associated with self-reported disability (descriptive synthesis: 6 studies), worse recovery (descriptive synthesis: 5 studies), and slower traffic injury-related claim closure (1 study), but not pain or work-related outcomes. Depressive symptoms were associated with greater primary healthcare utilization for acute LBP (1 confirmatory study). For chronic LBP, depressive symptoms were associated with higher pain intensity (descriptive synthesis: 9 studies; meta-analysis: 3 studies, 2902 participants, β=0.11, 95% confidence interval (CI) 0.05-0.17), disability (descriptive synthesis: 6 studies; meta-analysis: 5 studies, 3549 participants, β=0.16, 95% CI 0.04-0.29), and worse recovery (descriptive synthesis: 2 studies; meta-analysis: 2 studies, 13,263 participants, relative risk (RR)=0.91, 95% CI 0.88-0.95), but not incident chronic widespread pain (1 study). DISCUSSION Depressive symptoms may be associated with self-reported disability and worse recovery in persons with acute and chronic LBP, and greater primary healthcare utilization for acute LBP. Our review provides high-quality prognostic factor information for LBP. Healthcare delivery that addresses depressive symptoms may improve disability and recovery in persons with LBP. Confirmatory studies are needed to assess the association between depressive symptoms and health outcomes in persons with LBP. PROTOCOL REGISTRATION PROSPERO database (CRD42019130047).
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Affiliation(s)
- Jessica J Wong
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada. .,Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, 2000 Simcoe Street North, Oshawa, Ontario, L1H 7K4, Canada.
| | - Andrea C Tricco
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada.,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th floor, Toronto, Ontario, M5B 1T8, Canada
| | - Pierre Côté
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada.,Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, 2000 Simcoe Street North, Oshawa, Ontario, L1H 7K4, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th floor, Toronto, Ontario, M5B 1T8, Canada.,Faculty of Health Sciences, Ontario Tech University, 2000 Simcoe Street North, Oshawa, Ontario, L1H 7K4, Canada
| | - Catherine Y Liang
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada
| | - Jeremy A Lewis
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada
| | - Zachary Bouck
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada.,Centre for Drug Policy and Evaluation, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, 3rd Floor, Toronto, Ontario, M5B 1T8, Canada
| | - Laura C Rosella
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada.,ICES, 155 College Street, Toronto, Ontario, M5T 3M7, Canada.,Stephen Family Chair in Community Health, Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, Ontario, L5B 1B8, Canada
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5
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Perruccio AV, Wong JT, Badley EM, Power JD, Yip C, Rampersaud YR. Predictors of response following standardized education and self-management recommendations for low back pain stratified by dominant pain location. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 8:100092. [PMID: 35141656 PMCID: PMC8820018 DOI: 10.1016/j.xnsj.2021.100092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Anthony V. Perruccio
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network; Toronto, ON, Canada
- Arthritis Community Research and Evaluation Unit, University Health Network; Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto; Toronto, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto; Toronto, ON, Canada
- Corresponding author at: Krembil Research Institute, 399 Bathurst St. - MP10-302, Toronto, ON M5T 2S8, Canada
| | - Jessica T.Y. Wong
- Dalla Lana School of Public Health, University of Toronto; Toronto, ON, Canada
| | - Elizabeth M. Badley
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network; Toronto, ON, Canada
- Arthritis Community Research and Evaluation Unit, University Health Network; Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto; Toronto, ON, Canada
| | - J. Denise Power
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network; Toronto, ON, Canada
| | - Calvin Yip
- Dalla Lana School of Public Health, University of Toronto; Toronto, ON, Canada
| | - Y. Raja Rampersaud
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network; Toronto, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto; Toronto, ON, Canada
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6
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Pinheiro CF, Bevilaqua-Grossi D, Florencio LL, Bragatto MM, Benatto MT, Dach F, Bigal ME, Carvalho GF. Is kinesiophobia related to fear of falling, dizziness disability, and migraine disability in patients with migraine? Physiother Theory Pract 2021; 38:2727-2735. [PMID: 34704520 DOI: 10.1080/09593985.2021.1996496] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Kinesiophobia is a common symptom associated with high disability, and has been observed in patients with migraine. However, the association between kinesiophobia and clinical factors in this population is unknown. OBJECTIVE To assess the fear of falling, dizziness disability, and migraine disability in patients with migraine, considering the presence of kinesiophobia. METHODS Eighty patients with migraine completed the Tampa Scale for Kinesiophobia and were divided into two groups according to the questionnaire cutoff point: migraine without kinesiophobia (MoK, n = 39) and migraine with kinesiophobia (MK, n = 41). Fear of falling, dizziness disability, and migraine disability were assessed in both groups using validated questionnaires. RESULTS The MK group presented higher scores on dizziness disability, fear of falling, and migraine disability compared to the MoK (p < .05). Kinesiophobia can explain 29% of the variance in dizziness disability and 18% of migraine disability. Both kinesiophobia and the presence of dizziness can explain 14% of fear of falling variability. Also, kinesiophobia is associated with the risk of presenting fear of falling (Prevalence Ratio = 2.4, p = .012), and migraine disability (Prevalence Ratio = 2.6, p = .01). CONCLUSION The presence of kinesiophobia should be considered in clinical practice when evaluating migraine, as it is associated with increased levels of fear of falling, dizziness disability, and migraine disability.
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Affiliation(s)
- Carina F Pinheiro
- Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Debora Bevilaqua-Grossi
- Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Lidiane L Florencio
- Department of Physiotherapy, Occupational Therapy, Physical Medicine and Rehabilitation - Rey Ruan Carlos University, Madrid, Spain
| | - Marcela M Bragatto
- Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Mariana T Benatto
- Department of Health Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Fabiola Dach
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Does Patient Body Mass Index Affect the Outcome of Multimodal Rehabilitation in Chronic Mechanical Low Back Pain? Spine (Phila Pa 1976) 2021; 46:1336-1343. [PMID: 34517403 DOI: 10.1097/brs.0000000000004000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective. OBJECTIVE The aim of this study was to investigate the effect of body mass index (BMI) on pain and disability in patients with chronic mechanical low back pain (LBP) treated with multimodal rehabilitation. SUMMARY OF BACKGROUND DATA Despite being a well-known risk factor for developing LBP, there is minimal data on the effect of BMI on pain and disability in patients with chronic mechanical low back pain (LBP) treated with multimodal rehabilitation. METHODS Data from patients with chronic mechanical LBP who underwent multimodal rehabilitation treatment at a chain of spine rehabilitation outpatient clinics in one of the three BMI groups-1564 patients in normal body weight (BMI ≥18.5-24.9), 1990 patients in overweight (BMI ≥25-29.9), and 891 patients in obese (BMI ≥ 30) groups-were retrospectively analyzed. Pre- and post-treatment Numerical Pain Rating Scale (NPRS) and Oswestry Disability Index (ODI) scores, and final treatment outcomes were compared between the three groups. Multivariate analysis was used to determine the association between pre-treatment covariates and post-treatment clinical outcomes. RESULTS Post-treatment, the mean NPRS (P = 0.005) and mean ODI (P < 0.001) scores were significantly higher with a significantly lower percentage of full success outcome (P = 0.009) in the obese group when compared to normal and overweight groups. However, multivariate analysis showed a significant correlation between age, the number of treatment sessions, pre-treatment NPRS and ODI scores, and post-treatment NPRS and ODI scores and treatment failure, and no correlation with patient BMI. CONCLUSION Patient BMI may not affect pain and disability outcomes in patients undergoing a multimodal rehabilitation treatment for chronic LBP. In contrast to BMI, other covariates such as age, treatment sessions, and pre-treatment NPRS and ODI scores may be associated with increased risk for poor treatment outcome. Obese individuals can expect clinical outcomes similar to normal or overweight individuals with multimodal physical rehabilitation for chronic LBP.Level of Evidence: 3.
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Ahmed UA, Maharaj SS, Van Oosterwijck J. Effects of dynamic stabilization exercises and muscle energy technique on selected biopsychosocial outcomes for patients with chronic non-specific low back pain: a double-blind randomized controlled trial. Scand J Pain 2021; 21:495-511. [PMID: 33641272 DOI: 10.1515/sjpain-2020-0133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/12/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Low back pain is the most prevalent musculoskeletal condition, and causes activity limitations which result in reduced work productivity and high medical expenditure. The management of this condition has been challenging to both clinicians and researchers. While the use of Muscle Energy Technique (MET) as a potentially effective treatment strategy seems promising, studies examining MET combined with exercise therapy are scarce and studies with strong methodology are lacking. Therefore, this study aims to determine the effects of a combination of Dynamic Stabilization Exercises (DSE) and MET on selected biopsychosocial outcomes compared to DSE alone or conventional physiotherapy in the management of chronic non-specific low back pain (NSLBP). METHODS A total of 125 (80 male and 45 female) patients with chronic NSLBP were involved in this study, they were recruited from Rasheed Shekoni Teaching hospital and Federal Medical centre Birnin-Kudu, Jigawa State, Nigeria. A random number generator method was used to allocate patients to either DSE + MET (n=41), DSE alone (n=39) or conventional physiotherapy (n=45). Interventions were administered twice a week over 12 weeks. Outcome measures included pain intensity, lumbar (flexion and extension) range of motion, functional-disability, self-perceived health status, limitations in activities and participation restrictions. These were assessed at baseline, mid-intervention at six weeks, post-intervention at 12 weeks and long term follow-up at 24 weeks. Data was analyzed using repeated-measures ANOVA to determine significance difference within groups and between groups. RESULTS All intervention groups showed within-groups changes of the study outcomes over time (p<0.001). However, between-group comparisons showed greater improvements in pain intensity (F=7.91, p<0.001), lumbar ROM (flexion F=1.51, p<0.001; extension F=3.25, p<0.001), activity limitations/participation restrictions (F=3.7, p<0.001) and health status (F=10.9, p<0.001) for the intervention in which MET and DSE were combined. The MET plus DSE interventions were superior to DSE and convention physiotherapy for all outcome measures, except for functional disability (F=0.53, p=0.590). CONCLUSIONS The data from this study showed MET combined with DSE had greater therapeutic benefits compared to DSE or conventional physiotherapy on selected biopsychosocial outcomes in patients with chronic NSLBP. The findings from the study show that the combination of MET with DSE is safe and has beneficial effects in the management of patients with chronic NSLBP. CLINICAL TRIAL REGISTRATION The study protocol has been registered with www.ClinicalTrial.gov with the registration number NCT3449810.
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Affiliation(s)
- Usman Abba Ahmed
- Department of Physiotherapy, Rasheed Shekoni Specialist Hospital, Dutse, Jigawa State, Nigeria
- Division of Physiotherapy, School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sonill Sooknunan Maharaj
- Division of Physiotherapy, School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jessica Van Oosterwijck
- Department of Rehabilitation Sciences, SPINE Research Unit Ghent, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Research Foundation - Flanders (FWO), Brussels, Belgium
- Pain in Motion, International Research Group, Brussels, Belgium
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9
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Adnan R, Van Oosterwijck J, Danneels L, Willems T, Meeus M, Crombez G, Goubert D. Differences in psychological factors, disability and fatigue according to the grade of chronification in non-specific low back pain patients: A cross-sectional study. J Back Musculoskelet Rehabil 2021; 33:919-930. [PMID: 33016899 DOI: 10.3233/bmr-191548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Differences in pain processing, muscle structure and function have been reported in patients with low back pain (LBP) with different grades of pain chronicity. OBJECTIVE The present study aims to examine differences in psychological factors, disability and subjective fatigue between subgroups of LBP based on their chronification grade. METHODS Twenty-one healthy controls (HC) and 54 LBP patients (categorized based on the grades of chronicity into recurrent LBP (RLBP), non-continuous chronic LBP (CLBP), or continuous (CLBP)) filled out a set of self-reporting questionnaires. RESULTS The Hospital Anxiety and Depression Scale (HADS) and Multidimensional Pain Inventory (MPI) scores indicated that anxiety, pain severity, pain interference and affective distress were lower in HC and RLBP compared to non-continuous CLBP. Anxiety scores were higher in non-continuous CLBP compared to RLBP, continuous CLBP and HC. The Pain Catastrophizing Scale for Helplessness (PSCH) was higher in non-continuous CLBP compared to HC. The Survey of Pain Attitudes (SOPA) showed no differences in adaptive and maladaptive behaviors across the groups. The Pain Disability Index (PDI) measured a higher disability in both CLBP groups compared to HC. Moreover, the Rolland Morris Disability Questionnaire (RMDQ) showed higher levels of disability in continuous CLBP compared to non-continuous CLBP, RLBP and HC. The Checklist Individual Strength (CIS) revealed that patients with non-continuous CLBP were affected to a higher extent by severe fatigue compared to continuous CLBP, RLBP and HC (subjective fatigue, concentration and physical activity). For all tests, a significance level of 0.05 was used. CONCLUSIONS RLBP patients are more disabled than HC, but have a tendency towards a general positive psychological state of mind. Non-continuous CLBP patients would most likely present a negative psychological mindset, become more disabled and have prolonged fatigue complaints. Finally, the continuous CLBP patients are characterized by more negative attitudes and believes on pain, enhanced disability and interference of pain in their daily lives.
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Affiliation(s)
- Rahmat Adnan
- SPINE Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Belgium.,Faculty of Sports Science and Recreation, Universiti Teknologi MARA, Malaysia
| | - Jessica Van Oosterwijck
- SPINE Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Belgium.,Research Foundation - Flanders (FWO), Belgium.,Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Lieven Danneels
- SPINE Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Belgium
| | - Tine Willems
- SPINE Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Belgium
| | - Mira Meeus
- SPINE Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Belgium.,Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Geert Crombez
- Department of Experimental - Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, Ghent University, Belgium
| | - Dorien Goubert
- SPINE Research Unit Ghent, Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Belgium
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10
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Construct Validity and Reliability of the Japanese Version of the Lumbar Stiffness Disability Index. Spine (Phila Pa 1976) 2021; 46:E333-E337. [PMID: 33156281 DOI: 10.1097/brs.0000000000003772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Outcome study to determine the construct validity and reliability of the Japanese version of the Lumbar Stiffness Disability Index. OBJECTIVE The aim of this study was to evaluate the psychometric measurement properties of the Japanese version of the Lumbar Stiffness Disability Index (J-LSDI) following lumbar spinal surgery in order to assess its construct validity and reliability. SUMMARY OF BACKGROUND DATA The LSDI was designed and validated as a tool to assess functional impacts of lumbar spine stiffness and diminished spinal flexibility. A Japanese version has been developed, but its construct validity and reliability have not been evaluated. METHODS A Pearson correlation coefficient was calculated using flexion and extension range of motion, Oswestry Disability Index (ODI) and Tampa Scale for Kinesiophobia (TSK) as external standards to evaluate construct validity. An intraclass correlation coefficient (ICC) and a Bland-Altman analysis were used to evaluate test-retest reliability. RESULTS A total of 244 patients following lumbar spinal surgery participated in the study. Fifty one of the 244 patients participated in the reliability study. The ICC of the J-LSDI for test-retest reliability was 0.89 (95% confidence interval, 0.79-0.93). There was no systematic error found in the results of the Bland-Altman analysis. One hundred ninety-three of the 244 patients participated in the validity study. There were significant correlations between the J-LSDI and trunk flexion range of motion (r = -0.66), extension (r = -0.51), ODI (r = 0.62), and TSK (r = 0.38). CONCLUSION The construct validity and reliability of the Japanese version of the LSDI were confirmed. The J-LSDI can be used to evaluate lumbar stiffness and associated disability in Japanese patients following lumbar spinal surgery.Level of Evidence: 2.
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Chen L, Ferreira ML, Beckenkamp PR, Caputo EL, Feng S, Ferreira PH. Comparative Efficacy and Safety of Conservative Care for Pregnancy-Related Low Back Pain: A Systematic Review and Network Meta-analysis. Phys Ther 2021; 101:5991225. [PMID: 33210717 DOI: 10.1093/ptj/pzaa200] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/23/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE More than one-half of pregnant women experience pregnancy-related low back pain (LBP). Pregnancy-related LBP greatly affects activities of daily life, and although many interventions have been proposed, the optimal treatment for pregnancy-related LBP remains unclear. The purpose of this study was to compare conservative care strategies on their efficacy and safety for women with pregnancy-related LBP through systematic review with pairwise meta-analysis and network meta-analysis. METHODS MEDLINE, Embase, the Cochrane Library, AMED, CINAHL, PEDro, PsycINFO, and ClinicalTrials.gov were searched from inception to November 2019. Randomized controlled trials and observational controlled studies were included without restriction to language, sample size, or duration of follow-up. Two independent investigators extracted the data and assessed the risk of bias. The quality of evidence was evaluated through Grading of Recommendations Assessment, Development and Evaluation. RESULTS Twenty-three studies were included in the qualitative synthesis (18 randomized controlled trials were included in the network meta-analysis). For women with LBP during pregnancy, progressive muscle relaxation therapy (mean difference = -3.96; 95% CI = -7.19 to -0.74; moderate-quality evidence) and Kinesio Taping (mean difference = -3.71; 95% CI = -6.55 to -0.87; low-quality evidence) reduced pain intensity (Visual Analog Scale, range = 0 to 10) compared with placebo. Moderate-quality evidence suggested that transcutaneous electrical nerve stimulation improved physical function (mean difference = -6.33; 95% CI = -10.61 to -2.05; Roland Morris Disability Questionnaire, range = 0-24) compared with placebo. CONCLUSION For patients with LBP during pregnancy, progressive muscle relaxation therapy and Kinesio Taping may help to decrease pain, and transcutaneous electrical nerve stimulation may improve physical function. IMPACT This review helps fill the gap in evidence regarding optimal treatment for pregnancy-related LBP. LAY SUMMARY If you have LBP during pregnancy, your physical therapist has evidence to support the use of progressive muscle relaxation therapy and Kinesio Taping to help decrease pain and the use of transcutaneous electrical nerve stimulation to help improve physical function.
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Affiliation(s)
- Lingxiao Chen
- Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Manuela L Ferreira
- Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Paula R Beckenkamp
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Eduardo L Caputo
- Postgraduate Program in Physical Education, Federal University of Pelotas, Pelotas, Brazil
| | - Shiqing Feng
- Department of Orthopaedics, Tianjin Medical University General Hospital, Tianjin, China
| | - Paulo H Ferreira
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia
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Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aim of this study was to identify treatment response trajectories in patients with low back pain (LBP) during and after multidisciplinary care in a tertiary spine center, and to examine baseline patient characteristics that can distinguish trajectories. SUMMARY OF BACKGROUND DATA Treatment response is often heterogeneous between patients with LBP. Knowledge on key characteristics that are associated with courses of disability could identify patients at risk for less favorable outcome. This knowledge will help improve shared decision-making. METHODS Adult patients with LBP completed questionnaires on disability (Pain Disability Index) and LBP impact (Impact Stratification of the National Institutes of Health minimal dataset) at baseline, 6, 12, 18, and 24 months' follow-up. Latent class analyses were applied to identify trajectories of disability and LBP impact. Baseline sociodemographic and clinical patient characteristics were compared between trajectory subgroups. RESULTS Follow-up was available for 996 patients on disability and 707 patients on LBP impact. Six trajectories were identified for both outcome measures. Three disability trajectories remained stable at distinct levels of severity (68% of patients) and three trajectories showed patterns of recovery (32%). For LBP impact there was one stable trajectory (17%), two slightly improving (59%), two recovering (15%), and one with a pattern of recovery and relapse (15%). Significant differences between trajectories were observed for almost all baseline patient characteristics. CONCLUSION On average, patients show moderate improvements in disability and LBP impact 2 years after visiting a multidisciplinary tertiary spine center. However, latent class analyses revealed that most patients belong to subgroups experiencing stable levels of disability and LBP impact. Differences in baseline patient characteristics were mostly associated with baseline levels of functioning, instead of (un)favorable outcome during follow-up. LEVEL OF EVIDENCE 2.
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Wong JJ, Tricco AC, Côté P, Rosella LC. The association between depressive symptoms or depression and health outcomes in adults with low back pain with or without radiculopathy: protocol of a systematic review. Syst Rev 2019; 8:267. [PMID: 31703727 PMCID: PMC6839250 DOI: 10.1186/s13643-019-1192-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 10/09/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND A considerable proportion of adults with low back pain (LBP) suffer from depressive symptoms or depression. Those with depressive symptoms or depression may be at risk of poorer LBP recovery and require more health care. Understanding the role of prognostic factors for LBP is critically important to guide management and health services delivery. Our objective is to conduct a systematic review to assess the association between depressive symptoms or depression and health outcomes in adults with LBP with or without radiculopathy. METHODS Electronic databases including MEDLINE, Embase, CINAHL, and PsycINFO will be searched from inception to April 2019 to identify relevant studies. Additional citations will be identified by searching reference lists of included studies and related systematic reviews. Cohort and case-control studies assessing the association between depressive symptoms/depression and health outcomes in adults aged 16 years and older with LBP with or without radiculopathy will be included. The following will be included: depressive symptoms as measured on standardized questionnaires (e.g., Center for Epidemiologic Studies Depression Scale, Beck Depression Index), and depression as standardized diagnoses (e.g., International Classification of Diseases codes) or self-reported depression diagnosis on standardized questionnaires. Outcomes of interest are standardized measures for pain, disability, overall health status, satisfaction with care, and health care utilization. These are informed by core outcome domains that international expert panels consider important for LBP research. Pairs of reviewers will screen articles retrieved from the search, extract data, and assess risk of bias using the Risk Of Bias In Non-randomized Studies-of Exposures (ROBINS-E) tool. Reviewers will use these criteria to inform their judgment on the internal validity of studies (e.g., low, moderate, or high risk of bias). If studies are deemed homogeneous, a random effects meta-analysis on the association between depressive symptoms and health outcomes will be performed. The results of the included studies will be descriptively outlined if studies are deemed heterogeneous. DISCUSSION The impact of depressive symptoms and depression on health- and health care-related outcomes for LBP with or without radiculopathy will be assessed and quantified. Findings of this systematic review will advance our understanding of LBP prognosis, and guide decision-making and improve quality of care for adults with LBP. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019130047.
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Affiliation(s)
- Jessica J. Wong
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON M5T 3M7 Canada
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, 2000 Simcoe Street North, Oshawa, ON L1H 7K4 Canada
| | - Andrea C. Tricco
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON M5T 3M7 Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Knowledge Translation Program, 209 Victoria Street, East Building, Room 716, Toronto, ON M5B 1W8 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th floor, Toronto, ON M5T 3M7 Canada
| | - Pierre Côté
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON M5T 3M7 Canada
- Centre for Disability Prevention and Rehabilitation, Ontario Tech University and Canadian Memorial Chiropractic College, 2000 Simcoe Street North, Oshawa, ON L1H 7K4 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th floor, Toronto, ON M5T 3M7 Canada
- Faculty of Health Sciences, Ontario Tech University, 2000 Simcoe Street North, Oshawa, ON L1H 7K4 Canada
| | - Laura C. Rosella
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON M5T 3M7 Canada
- ICES, 155 College Street, Toronto, ON M5T 3M7 Canada
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Ferrari S, Vanti C, Pellizzer M, Dozza L, Monticone M, Pillastrini P. Is there a relationship between self-efficacy, disability, pain and sociodemographic characteristics in chronic low back pain? A multicenter retrospective analysis. Arch Physiother 2019; 9:9. [PMID: 31632695 PMCID: PMC6790029 DOI: 10.1186/s40945-019-0061-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 09/12/2019] [Indexed: 12/15/2022] Open
Abstract
Background Pain-related self-efficacy is defined as the beliefs held by people with chronic pain that certain activities can be carried out despite the pain. Poor self-efficacy is an obstacle to the recovery and predicts long-term disability. The aims of this study are to investigate the prevalence of poor pain self-efficacy in Italian subjects with chronic low back pain (LBP), and to inquire the relationships between self-efficacy, disability, pain, and main demographic and clinical characteristics. Methods A secondary multicenter retrospective analysis was done on 310 outpatients with chronic non-specific LBP. The pain self-efficacy measured with the Pain Self-Efficacy Questionnaire (PSEQ), the disability measured with the Roland & Morris Disability Questionnaire, and the pain intensity measured with the Numerical Rating Scale were considered variables to investigate, whereas demographic and clinical variables were considered predictors or potential confounders. A 40/60 PSEQ score was adopted as cut-off to distinguish between good and poor self-efficacy. Results 199 subjects (64.2% of the sample) showed poor self-efficacy. The odds of having poor self-efficacy appeared significantly related to female gender (OR = 1.80, 95%CI [1.12;2.90]; p = 0.015) and drugs use (OR = 1.68, 95%CI [1.06;2.70]; p = 0.029). Significant relationships also emerged between disability and higher age (β = 0.07, 95%CI [0.01; 0.12]; p = 0.02), being female (β = 1.80, 95%CI [0.32;3.29]; p = 0.018), low educational level (β = − 1.68, 95%CI [− 2.59;-3.29]; p < 0.001), higher height (β = − 0.08, 95%CI [− 0.158;-0.002]; p = 0.045), pain duration [mos] (β = 0.01, 95%CI [0.001;0.021]; p = 0.041), and drugs use (β = 2.86, 95%CI [1.44;4.27]; p < 0.001). The amount of pain appeared significantly related to educational level (β = − 0.47, 95%CI [− 0.76;-0.182]; p < 0.001), smoking (β = 0.56, 95%CI [0.09; 1.03]; p = 0.021), height (β = − 0.03, 95%CI [− 0.05; − 0.002]; p = 0.036), and drugs use (β = 0.81, 95%CI [0.399;1.22]; p < 0.001). No significant correlation appeared among weight, body mass index, and referred pain neither in relation to self-efficacy, nor in relation to pain/disability. Conclusions The majority of our sample, composed of Italian people complained of chronic LBP, shows poor self-efficacy. Female gender and drugs use are significantly related to poor self-efficacy, low educational level negatively influences the amount of perceived pain and disability, and older age and smoking are related to disability and pain intensity, respectively. The knowledge of these sociodemographic and clinical characteristics potentially influencing chronic LBP may be useful to address more efforts towards the most negatively impacted subjects, among the entire population complained of chronic LBP.
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Affiliation(s)
- Silvano Ferrari
- 1Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Carla Vanti
- 2Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marta Pellizzer
- Public Health Company - ULSS 7 Pedemontana, Bassano del Grappa, VI Italy
| | - Luca Dozza
- 4Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marco Monticone
- 5Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Paolo Pillastrini
- 2Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Benatto MT, Bevilaqua-Grossi D, Carvalho GF, Bragatto MM, Pinheiro CF, Straceri Lodovichi S, Dach F, Fernández-de-Las-Peñas C, Florencio LL. Kinesiophobia Is Associated with Migraine. PAIN MEDICINE 2019; 20:846-851. [PMID: 30462312 DOI: 10.1093/pm/pny206] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to assess kinesiophobia in patients with migraine and to determine its association and correlation with cutaneous allodynia and clinical manifestations of migraine. DESIGN A cross-sectional study. SETTING A headache clinic of a university-based hospital. SUBJECTS Eighty-nine patients diagnosed with migraine by a neurologist specialized in headache. METHODS Patients completed the Tampa Scale for Kinesiophobia (TSK) and the 12-item Allodynia Symptom Checklist (ASC-12) and described the frequency, duration, and intensity of migraine attacks, as well as number of years with migraine. RESULTS The prevalence of kinesiophobia was 53%, and it was associated with the classification of severe cutaneous allodynia (X2= 9.96, P = 0.02) but not with its presence (X2= 3.11, P = 0.07). Kinesiophobia and clinical migraine features were not significantly associated (P > 0.05), nor were TSK score, ASC-12 score, or clinical migraine features (r < 0.21, P > 0.05). Subjects with migraine, with or without kinesiophobia, believed that physical activity could not help to control or relieve their pain, and those with kinesiophobia, furthermore, believed that exercise may be harmful. CONCLUSIONS Kinesiophobia is present in about half of migraineurs. It was associated with worsened cutaneous allodynia severity, but not with its presence, in patients with migraine. Education strategies should be implemented as negative beliefs related to exercise are present despite its evidence of benefit in migraine treatment.
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Affiliation(s)
| | | | | | | | | | | | - Fabíola Dach
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Lidiane Lima Florencio
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
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