Determinants of chronic disability related to low back pain: towards an integrative biopsychosocial model

The use of a biopsychosocial model in the treatment of patients with chronic

OBJECTIVE

To explore the available knowledge on the application of biopsychosocial model (BPS) in patients with chronic low back pain (CLBP).

METHODS

A scoping review, including 32 papers that used a BPS to manage adult patients with CLBP, published in any language. Six different databases were searched.

RESULTS

According to the description of the protocols, most of them use BPS for assessment of the patients. In this first stage the most often evaluated were pain and disability, kinesiophobia and quality of life, and work-related factors. The intervention most used associate psychological and physical domains using pain education or cognitive functional therapy and active exercise. Even though was not the most common, in the social domain occupational, behavioral and family interventions were observed.

CONCLUSION

BPS is more often used as combination of physical and psychological aspects, being the social domain restricted to work-related factors. Patien'ts perception of their health status is little explored, and it is suggested that the International Classification of Functioning, Disability and Health be used.

PRACTICE IMPLICATION

Patient perception as well as social factors in addition to occupational ones should be included in the clinical approach of the patient with CLBP and should be further explored in research.

Predictive performance of the STarT Back tool for poor outcomes in patients with low back pain: protocol for a systematic review and meta-analysis

INTRODUCTION

Subgroups for Targeted Treatment Back Tool (SBT) is a brief multiple-construct risk prediction tool for patients with low back pain (LBP). Thus far, the predictive ability of this tool has been inconsistent. Therefore, we aim to conduct a literature review on the predictive ability of the SBT to determine the outcomes of patients with LBP. The results of this review should improve the ability of the SBT to predict poor outcomes in patients with LBP.

METHODS AND ANALYSIS

Databases including PubMed, EMBASE, Cochrane Central, Web of Science, Chinese National Knowledge Infrastructure Databases, Chinese Science and Technology Journal Database, and Wanfang will be searched for studies on SBT and LBP from their inception until 31 March 2023. Longitudinal studies investigating the association between SBT subgroups and LBP outcomes, including pain, disability and quality of life, will be included. The identified studies will be independently screened for eligibility by two reviewers. A standardised sheet will be used to extract data. The Newcastle-Ottawa Scale will be used to assess the methodological quality of the included studies. Heterogeneity will be evaluated by the χ2 test with Cochran's Q statistic and quantified by the I2 statistic. The results will be synthesised qualitatively and presented as pooled risk ratios or beta coefficients quantitatively. The results will also be presented using their 95% confidence limits. Publication bias will be assessed using the method proposed by Egger and by visual inspection of funnel plots.

ETHICS AND DISSEMINATION

This study is a secondary analysis of original studies that received ethics approval. Therefore, prior ethical approval is not required for this study. The findings will be submitted to relevant peer-reviewed journals for publication and presented at profession-specific conferences.

TRIAL REGISTRATION NUMBER

PROSPERO registration numberCRD42022309189.

Effectiveness of coordinated care to reduce the risk of prolonged disability among patients suffering from subacute or recurrent acute low back pain in primary care: protocol of the CO.LOMB cluster-randomized, controlled study

Background

Low back pain (LBP) is a common musculoskeletal condition and, globally, a leading cause of years lived with disability. It leads to reduced social participation, impaired quality of life, and direct and indirect costs due to work incapacity. A coordinated approach focusing on psychosocial risk factors, active reeducation, and the early use of tools to maintain employment, may be effective for improving prognosis of patients with LBP. Primary care professionals and multidisciplinary teams, who see patients in the early stages of LBP may be in the best position to implement such a coordinated approach. We designed this study to assess a coordinated multi-faceted strategy in primary care for patients with subacute or recurrent acute LBP.

Methods

The CO.LOMB study was designed as a multicentric, cluster-randomized, controlled study. Patients aged 18-60 years, with subacute or recurrent acute LBP are eligible. Patients also need to be employed (but can be on sick leave) with access to occupational health services. The clusters of GPs will be randomized (1:1) to either the Coordinated-care group or the Usual-care group. Patients will be assigned the group allocated to their GP. The healthcare professionals (GPs and associated physiotherapists) allocated to the Coordinated-care group will perform a 2-session study training. The following interventions are planned in the Coordinated-care group: exploration and management of psychosocial factors, active reeducation with a physiotherapist, the implementing of tools to maintain employment, and a reinforced cooperation between primary healthcare professionals. The primary objective is to assess the benefit of coordinated primary care to reduce disability in LBP patients at 12 months after enrollment: measure using the validated French version of the Roland Morris Disability Questionnaire. Secondary objectives include the evaluation of pain, work status, and quality of life at various time points. The study plans to enroll 500 patients in 20 GP clusters. Patients will be followed up for 12months.

Discussion

This study will evaluate the benefit of a coordinated multi-faceted strategy in primary care for patients with LBP. Notably whether this approach will alleviate the associated disability, attenuate pain, and promote the maintenance or return to work.

Clinical Trial Registration

NCT04826757.

Associations between social integration, participation and productivity loss among persons with chronic pain: a registry based cross sectional study

Purpose

To examine associations between factors of social inclusion and participation and productivity loss in employed persons with chronic pain, assessed for an interprofessional pain rehabilitation programme. We hypothesized that factors of social inclusion and participation and work related social factors are significantly associated with productivity when experiencing chronic pain and we expected a moderate effect.

Methods

Cross-sectional study using data collected prospectively in an interprofessional patient registry for chronic pain. The primary end point was productivity loss, measured with the iMTA Productivity Costs Questionnaire. We included data from 161 individuals. To be included, persons had to be 18 years old or older, in paid work, and had to have a medical diagnosis of chronic pain syndrome with actual or potential tissue damage. In addition, participants had to have indicators of significant impairments in psychosocial functions.

Results

Linear regression analysis showed that a highly stressful professional situation, frequent problems regarding the compatibility of the family and job and not being Swiss were associated with a significantly higher total productivity loss. Similar results were found for productivity loss in paid work. However, problems concerning the compatibility of the family and job did not reach the significance level for productivity loss in paid work.

Conclusion

The results of this study underscore the importance of factors of social inclusion and participation for interprofessional rehabilitation programmes to manage chronic pain especially when focussing on productivity loss.

Feasibility, Usability, and Implementation Context of an Internet-Based Pain Education and Exercise Program for Chronic Musculoskeletal Pain: Pilot Trial of the ReabilitaDOR Program

Background

Internet-based self-management programs and telerehabilitation initiatives have increased and have been extensively used for delivering health care in many areas. These programs overcome common barriers that patients face with traditional face-to-face health care, such as travel expenditures, lack of time, and high demand on the public health system. During the COVID-19 pandemic, this mode of web-based health care delivery had become more popular. However, there is still a lack of studies testing this mode of delivery in low- and middle-income countries. To gain a better understanding of the context, feasibility, and factors involved in the implementation of a web-based program, pilot and implementation studies are necessary. These studies can better inform whether a strategy is feasible, acceptable, and adequate for its purposes and for optimizing resource allocation.

Objective

This study aims to evaluate the feasibility, usability, and implementation context of a self-management internet-based program based on exercises and pain education (ReabilitaDOR) in people with chronic musculoskeletal pain and to compare this program with a program using only a web-based self-management booklet.

Methods

The study design was a parallel pilot study of a prospectively registered, assessor-blinded, 2-arm randomized controlled trial with economic evaluation. This study was performed using waiting lists of physiotherapy and rehabilitation centers and advertisements on social media networks. The participants were 65 patients with chronic musculoskeletal pain aged between 18 and 60 years. The effects of an 8-week telerehabilitation program based on exercises and pain education (intervention group) were compared with those of a program based only on a web-based self-management booklet (control group). The main outcome measures were implementation outcomes of patients’ perceptions of acceptability, appropriateness, feasibility, and usability of the program and the societal costs and feasibility of the main trial at 8-week posttreatment follow-up. Adverse events were also analyzed.

Results

In total, 56 participants were analyzed at the 8-week follow-up. The intervention group showed responses with a mean of 4.5 (SD 0.6) points for acceptability, 4.5 (SD 0.5) points for appropriateness, and 4.5 (SD 0.6) points for feasibility measured on a 1 to 5 scale. All patients in the intervention group showed satisfactory responses to the system usability outcome. There is satisfactory evidence for the feasibility of the main trial. For costs related to the interventions, health care, patients, and loss of productivity at 8 weeks, we found a total expenditure of US $278.30 per patient in the intervention group and US $141.52 per patient in the control group. No adverse events were reported during the intervention period.

Conclusions

We found that the ReabilitaDOR program is feasible, appropriate, and acceptable from the users’ implementation perspective. This system was considered usable by all the participants, and the main trial seemed feasible. Cost data were viable to be collected, and the program is likely to be safe.

Trial Registration

ClinicalTrials.gov NCT04274439; https://clinicaltrials.gov/ct2/show/NCT04274439

Stress Mindset and Social Identification in Chronic Pain Patients and Their Relationship to Coping, Well-Being & Depression

We predicted that chronic pain patients have a more negative stress mindset and a lower level of social identification than people without chronic pain and that this, in turn, influences well-being through less adaptive coping. 1240 participants (465 chronic pain patients; 775 people in the control group) completed a cross-sectional online-survey. Chronic pain patients had a more negative stress mindset and a lower level of social identification than people without chronic pain. However, a positive stress mindset was linked to better well-being and fewer depressive symptoms, through the use of the adaptive coping behaviors positive reframing and active coping. A higher level of social identification did not impact well-being or depression through the use of instrumental and emotional support coping, but through the more frequent use of positive reframing and active coping. For chronic pain therapy, we propose including modules that foster social identification and a positive stress mindset.

Influence of low back pain characteristics on the healthcare procedures prescribed by general practitioners for adult patients: ancillary analysis of the French ECOGEN study

BACKGROUND

Non-specific low back pain is a frequent reason for consultation, yet little is known about how general practitioners manage it in France.

OBJECTIVES

To describe the healthcare procedures general practitioners prescribe for low back pain in France.

MATERIALS AND METHODS

This is an ancillary analysis of an observational, cross-sectional study (ECOGEN) conducted between November 2011 and April 2012 among 128 general practitioners. Adults younger than 65 years consulting for low back pain were included. Patient and general practitioner characteristics, consultation results (diagnosis) and healthcare procedures were collected and coded using the International Classification in Primary Care. Analyses focused on the initial or follow-up consultation, adjusting on age, gender, and socio-occupational category.

RESULTS AND DISCUSSION

Out of 11510 consultations, 845 (7.3%) were for low back pain. Of these, 776 (79.5%) resulted in a clinical examination, 634 (73.4%) in medication prescription, and 203 (23.9%) were prescribed sick leave, but imaging and specialist referral were rare. Imaging was more frequent with radiating pain (adjusted odds ratio (aOR) = 1.61; 95% CI [1.07, 2.42]), as were specialist referrals (OR = 2.92; 95% CI [1.40, 6.09]) and sick leave prescription (aOR = 1.52; 95% CI [1.10, 2.09]), but physiotherapist referral was less frequent (aOR = 0.55; 95% CI [0.38, 0.82]). Clinical examinations (aOR = 2.75; 95% CI [1.98, 3.80]), imaging (aOR = 1.61; 95% CI [1.02, 2.31]) and medication prescriptions (aOR = 2.34; 95% CI [1.65, 3.30]) were more common in initial consultations, but specialist referral (aOR = 0.16; 95% CI [0.05, 0.47]) or sick leave prescription (aOR = 0.68; 95% CI [0.48, 0.97]) were rarer.

CONCLUSION

Low back pain characteristics could influence healthcare procedures more markedly than patient or general practitioner characteristics.

Translation and Adaptation of the French Version of the Risk Stratification Index, a Tool for Stratified Care in Chronic Low Back Pain: A Pilot Study

Background and Objectives: Low back pain is a worldwide health problem. An early diagnosis is required to develop personalized treatment strategies. The Risk Stratification Index (RSI) was developed to serve the purpose. The aim of this pilot study is to cross-culturally translate the RSI to a French version (RSI-F) and evaluate the test-retest reliability of RSI-F using a French active population. Materials and Methods: The RSI was translated from German to French (RSI-F) based on the guidelines of cross-cultural adaptation of self-report measures. A total of 42 French recreational athletes (age 18−63 years) with non-specific low back pain were recruited and filled in the RSI-F twice. The test-retest reliability was examined using intraclass correlation coefficient (ICC1,2) and Pearson correlation coefficient. Results: Finally, 33 questionnaires were analyzed (14 males and 19 females, age 31 ± 10 years, 9.5 ± 3.2 h/week of training). The test-retest of RSI-F CPI and DISS were excellent (CPI: ICC1,2 = 0.989, p < 0.001; r = 0.989, p < 0.001; DISS: ICC1,2 = 0.991, p < 0.001; r = 0.991, p < 0.001), as well as Korff pain intensity (ICC1,2 = 0.995, p < 0.001; r = 0.995, p < 0.001) and disability (ICC1,2 = 0.998, p < 0.001; r = 0.998, p < 0.001). Conclusion: The RSI-F is linguistically accurate and reliable for use by a French-speaking active population with non-specific low back pain. The RSI-F is considered a tool to examine the evolution of psychosocial factors and therefore the risk of chronicity and the prognostic of pain. Further evaluations, such as internal, external validity, and responsiveness should be evaluated in a larger population.

Low Risk for Persistent Back Pain Disability Is Characterized by Lower Pain Sensitivity and Higher Physical Performance

OBJECTIVE

The STarT Back Tool (SBT) predicts risk for persistent low back pain (LBP)-related disability based on psychological distress levels. Other non-psychological factors associated with LBP, such as pain sensitivity and physical performance, may further characterize SBT-risk subgroups. The purpose of this study was to determine whether a low-risk SBT subgroup demonstrated lower pain sensitivity and/or higher physical performance compared with a medium-/high-risk SBT subgroup.

METHODS

In this cross-sectional, secondary analysis, adults with LBP (N = 76) completed SBT and demographics (age, sex, race, chronicity) questionnaires. Participants underwent pain sensitivity (local and remote pressure pain thresholds, temporal summation, conditioned pain modulation) and physical performance (Back Performance Scale, walking speed, obstacle negotiation, Timed "Up & Go" [TUG], TUG Cognitive) testing. Independent samples t tests determined low- versus medium-/high-risk SBT subgroup differences. A follow-up discriminant function analysis was also conducted.

RESULTS

The medium-/high-risk subgroup demonstrated a lower proportion of participants with acute pain. The low-risk subgroup demonstrated lower pain sensitivity (higher local pressure pain thresholds and higher conditioned pain modulation) and higher physical performance (superior Back Performance Scale scores, faster walking speeds, faster obstacle approach and crossing speeds, and faster TUG completion). Discriminant function analysis results supported the 2-subgroup classification and indicated strong to moderate relationships with obstacle crossing speed, chronicity, and conditioned pain modulation.

CONCLUSION

Lower pain sensitivity and higher physical performance characterized the low-risk SBT subgroup and may represent additional LBP prognostic factors associated with persistent disability. Longitudinal studies are needed to confirm whether these factors can enhance SBT prediction accuracy and further direct treatment priorities.

IMPACT

Sensory and physical factors contribute to SBT risk classification, suggesting additional, non-psychological factors are indicative of favorable LBP outcomes. Findings highlight the need for assessment of multiple factors to improve LBP clinical prediction.

LAY SUMMARY

People at low risk for back pain disability have less sensitivity to pain and better physical performance. By measuring these factors, physical therapists could guide treatment and improve outcomes for people with back pain.

Effects of a multimodal exercise intervention on physical and cognitive functions in patients with chronic low back pain (MultiMove): study protocol for a randomized controlled trial

BACKGROUND

Chronic low back pain (CLBP) is a common medical condition in adults over the age of 50. It is associated with severe disability, ranging from physical impairments to psychosocial distress. Since current treatments provide only small to moderate short-term effects, alternative interventions are required, whereby guidelines recommended multimodal approaches. Dancing can be considered as an inherently multimodal approach, as it requires a combination of physical and cognitive functions. Furthermore, it has already been applied effectively in neurorehabilitation. Therefore, it seems promising to merge a dance-therapeutic component together with motor-cognitive, strength and flexibility exercises in a novel multimodal treatment (MultiMove) to target the impaired everyday mobility and cognition of CLBP patients. The aim of this study is to analyse specific physical, cognitive and psychosocial effects of MultiMove in CLBP patients.

METHODS

A prospective, two-arm, single-blinded, randomized controlled trial will be conducted with an estimated sample size of 100 CLBP patients, assigned to either the MultiMove group or a control group. The intervention group will receive MultiMove twice a week for 60 min each over a period of 12 weeks. The primary outcome will be the mobility and function of the lower extremities assessed by the Timed Up-and-Go Test. Secondary outcomes comprise further physical and physiological functions (e.g. gait variability and haemodynamic response in the prefrontal cortex during motor-cognitive dual tasks), subjective health state (e.g. disability in daily life), executive functions (e.g. cognitive flexibility) and psychosocial aspects (e.g. kinesiophobia). Measures will be taken at baseline, after the intervention and at a 12-week follow-up. It is assumed that MultiMove improves the mentioned outcome parameters.

DISCUSSION

The combined assessment of changes in physical and cognitive functions as well as neuropsychological aspects in response to MultiMove will allow a better understanding of the motor-cognitive adaptations induced by multimodal exercises in CLBP patients. The specific conclusions will lead to recommendations for the conservative treatment approach in this clinically relevant patient group.

TRIAL REGISTRATION

German Clinical Trial Register (ID: DRKS00021696 / 10.07.2020), https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021696.

Linear and Non-linear Dynamic Methods Toward Investigating Proprioception Impairment in Non-specific Low Back Pain Patients

Central nervous system (CNS) uses vision, vestibular, and somatosensory information to maintain body stability. Research has shown that there is more lumbar proprioception error among low back pain (LBP) individuals as compared to healthy people. In this study, two groups of 20 healthy people and 20 non-specific low back pain (NSLBP) participants took part in this investigation. This investigation focused on somatosensory sensors and in order to alter proprioception, a vibrator (frequency of 70 Hz, amplitude of 0.5 mm) was placed on the soleus muscle area of each leg and two vibrators were placed bilaterally across the lower back muscles. Individuals, whose vision was occluded, were placed on two surfaces (foam and rigid) on force plate, and trunk angles were recorded simultaneously. Tests were performed in eight separate trials; the independent variables were vibration (four levels) and surface (two levels) for within subjects and two groups (healthy and LBP) for between subjects (4 × 2 × 2). MANOVA and multi-factor ANOVA tests were done. Linear parameters for center of pressure (COP) [deviation of amplitude, deviation of velocity, phase plane portrait (PPP), and overall mean velocity] and non-linear parameters for COP and trunk angle [recurrence quantification analysis (RQA) and Lyapunov exponents] were chosen as dependent variables. Results indicated that NSLBP individuals relied more on ankle proprioception for postural stability. Similarly, RQA parameters for the COP on both sides and for the trunk sagittal angle indicated more repeated patterns of movement among the LBP cohort. Analysis of short and long Lyapunov exponents showed that people with LBP caused no use of all joints in their bodies (non-flexible), are less stable than healthy subjects.

Understanding Clinicians' Decisions to Assume Prescriptions for Inherited Patients on Long-term Opioid Therapy: A Qualitative Study

OBJECTIVE

Given the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy.

METHODS

We conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology.

RESULTS

We identified three approaches to assuming a new patient's opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians "dumping" patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses.

CONCLUSIONS

Clinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.

Evaluation of the efficacy of an internet-based pain education and exercise program for chronic musculoskeletal pain in comparison with online self-management booklet: a protocol of a randomised controlled trial with assessor-blinded, 12-month follow-up, and economic evaluation

BACKGROUND

Chronic musculoskeletal pain is one of the main causes of years lived with disability and generates the highest cost of health care among chronic pain conditions. Internet-based treatments have been shown to be an alternative for the treatment of musculoskeletal conditions, in addition to reducing barriers such as travel, high demands on the public health system, lack of time, lack of insurance coverage for private care, and high costs for long-term treatment. The aim of this clinical trial is to develop and test the effectiveness and cost-effectiveness of, an internet-based self-management program based on pain education and exercise for people with chronic musculoskeletal pain.

METHODS

This is a prospectively registered, assessor-blinded, two-arm randomised controlled trial with economic evaluation comparing the Internet-based pain education and exercise intervention with a control group that will receive an online booklet. One hundred and sixty patients will be recruited from Sao Paulo, Brazil. Follow-ups will be conducted in post-treatment, 6 and 12 months after randomisation. The conduct of the study, as well as the evaluations and follow-ups will be carried out entirely remotely, through online platforms and telephone calls. The primary outcome will be pain intensity at post-treatment (8 weeks) measured using the 11-item Pain Numerical Rating Scale. Secondary outcomes will be biopsychosocial factors presents in the chronic musculoskeletal pain condition. Costs due to chronic musculoskeletal pain will be also measured, and cost-effectiveness analysis from a societal perspective will performed.

DISCUSSION

Our hypothesis is that internet-based pain education and exercise will be better than an online booklet in reducing pain and improving biopsychosocial outcomes in patients with chronic musculoskeletal pain. In addition, we believe that there will be good acceptance of patients for the internet-based intervention and that internet-based intervention will be more cost effective than the online booklet.

TRIAL REGISTRATION

The study was prospectively registered at ClinicalTrials.gov ( NCT04274439 , registered 18 February 2020).

Back pain and depressive symptoms: A systematic review and meta-analysis

BACKGROUND

Low back pain is a common disorder that has many consequences. This study is an attempt to meta-analyze the risk of depression symptoms in back pain.

METHOD

Four databases were selected for review, and this search was conducted using key words. Eleven eligible articles were selected for review and meta-analysis was conducted. Subgroup analyses were continued with study design and the method of measuring depression. Also, the heterogeneity and publication bias were examined.

RESULTS

Eleven cohort and cross-sectional articles are used in the meta-analysis between back pain and depressive symptoms. The odds ratio 2.07 was calculated for this relationship. In prospective-cohort studies, 1.71 (95% confidence interval = 1.24-2.36) results indicated that back pain is a risk factor for depression symptoms and in cross-sectional studies, pooled odds ratio (2.33; 95% confidence interval = 1.29-4.21) showed that back pain is associated with depression symptoms. Some degree of publication bias was not found in the study.

CONCLUSIONS

Back pain is an effective factor in increasing the likelihood of depression. Adoption of effective prevention and treatment approaches can play an important role in reducing the psychological consequences in these individuals.

Community-based self-management of chronic low back pain in a rural African primary care setting: a feasibility study

A small pragmatic non-randomised controlled study investigated the feasibility and acceptability of a novel theory-informed community-based self-management programme targeting the biopsychosocial factors associated with chronic low back pain disability in a rural Nigerian primary care centre. Participants either received the programme, once weekly for 6 weeks, or usual care. The programme combined group exercise sessions with group/individual discussion sessions, informed by cognitive behavioural therapy and motivational interviewing. Recruitment rate, intervention delivery, proportion of planned treatment attended, retention/dropout rate, adherence to recommended self-management strategies and biopsychosocial outcomes were used to determine feasibility. Structured qualitative exit feedback interviews ascertained acceptability. Recruitment rate was 100%, treatment uptake was 83% and loss to follow-up was 8%. Greater benefits for the self-management group compared with control were observed for primary and secondary biopsychosocial outcomes. Although the programme appears promising, the exploratory design of this study warrants more rigorous intervention testing following suggested programme improvement.

Socioeconomic factors, psychological factors, and function in adults with chronic musculoskeletal pain from rural Nepal

Background

Both socioeconomic and psychological factors have been shown to predict patient function in samples of individuals with chronic pain in Western countries. However, little is known about their role as predictors of function in individuals with chronic pain from developing countries.

Purpose

The purpose of this study was to examine the associations between measures of socioeconomic factors (income, education) and psychological factors (catastrophizing and resilience) and measures of function in a sample of individuals with chronic pain from rural Nepal. In addition, we sought to evaluate the moderating effects of socioeconomic factors on the associations between the psychological variables and function.

Methods

We interviewed 143 adults with chronic musculoskeletal pain from rural areas of Nepal to assess income, education level, pain intensity, catastrophizing, resilience, physical function, and depression. We performed two regression analyses to evaluate the direct and unique effects of the socioeconomic and psychological variables and pain intensity as predictors of patient function, as well as the moderating influence of income, education level, and pain intensity on the associations between the psychological variables and function.

Results

Education and income both predicted physical function, but only income predicted depression. In addition, pain catastrophizing, but not resilience, evidenced a direct and significant independent association with depression. Neither catastrophizing nor resilience made independent and significant direct contributions to the prediction of physical function. The association between resilience and physical function was moderated by pain intensity and income, and income (but not education or pain intensity) moderated the associations between both 1) resilience and depression and 2) catastrophizing and depression.

Conclusion

The results suggest the possibility that cultural differences may influence the role that psychosocial factors play in chronic pain adjustment. These findings have important implications regarding how psychosocial pain interventions should be adapted by individuals in developing countries.

Predicting outcomes of acute low back pain patients in emergency department: A prospective observational cohort study

Low back pain (LBP) is a common complaint among patients presenting to emergency department (ED) in Singapore. The STarT Back Screening Tool (SBT) was recently developed and validated for triage of LBP patients in primary care settings. This study aimed to investigate whether the SBT could provide prognostic information for long-term outcomes of acute LBP patients visiting the ED, who might benefit from appropriate and timely management at an earlier stage.Data were collected in a prospective observational cohort study from 177 patients who consulted emergency physicians for acute LBP and completed 6-month follow-up. Patients were administered the SBT and assessed at baseline. Follow-up assessments were conducted at 6 weeks and 6 months.A multiple linear regression model incorporating SBT total score, age, employment status, LBP history, and 6-week pain score was constructed to predict 6-month pain score. In the model, SBT total score and 6-week pain score were significantly associated with 6-month pain score (P < .05) with respective coefficients of 0.125 and 0.500. The model explained 40.1% of the variance for 6-month pain score.This study demonstrated that the multiple linear regression model showed predictive performance in determining long-term outcomes for acute LBP patients presenting to the ED.

Development of a Self Report Stress Scale Using Item Response Theory-I: Item Selection, Formation of Factor Structure and Examination of Its Psychometric Properties

INTRODUCTION

Due to the absence of Turkish psychometric devices assessing stress, in the present study it was aimed to develop a stress scale, and examine its basic psychometric properties.

METHODS

Current study included two processes, formation of item pool and examination of psychometric properties of the selected items through three studies. In the first study, 611 individuals aged between 18 and 77 responded to 130 selected items. In the second study, 2223 individuals aged between 18 and 68 responded to 80 items. In the third study, 1969 individuals aged between 18 and 79 responded to the final form of 36 items. Further, in study 3 for criterion related validity 163 individuals completed the Coopersmith Self-Esteem Inventory, 113 individuals completed the Beck Anxiety Inventory, 104 individuals completed the Hospital Anxiety and Depression Scale, 107 individuals completed the Beck Depression Inventory, and 265 individuals completed the Perceived Stress Scale. Moreover, in the investigation of test-retest reliability, 119 individuals took the final form of the test after 2 weeks, and 111 individuals took the final form of the test after 3 weeks.

RESULTS

In the first study, out of 130 items, 54 that showed item-total score correlations below 0.30 were excluded from the scale. Fifty-seven items were preserved exactly, and 19 items' sentence structures were changed. Furthermore, by adding 4 new items, 80 were prepared for the second study. In the second study, two factors structure namely "Physiological Reactions/Strain" and "Psychological/Cognitive Appraisals" sub-dimensions were identified, and 36 items were selected via Item Response Theory representing these sub-dimensions. In study 3, exploratory factor analysis provided strong support for our hypothesized two factors structure. Confirmatory factor analysis indicated hypothesized model had a better fit to the data. Internal consistency coefficients were 0.94 for the entire scale, 0.90 for Physiological Reactions/Strain sub-dimension, and 0.91 for Psychological/Cognitive Appraisals sub-dimension. Correlation coefficients between the entire scale and other criterion scales ranged from 0.22 to 0.63. Test-retest correlation coefficients between the first administration of the scale, and the administrations at two and three week intervals were 0.88.

CONCLUSION

Results showed that the scale has basic psychometric requirements provided that the scale will be supported by validity studies.

Cognitive behavioural therapy and pain coping skills training for osteoarthritis knee pain management: a systematic review

[Purpose] To investigate the effectiveness of cognitive-behavioural therapy (CBT) and pain coping skills training (PCST) on pain level in adults with osteoarthritis of the knee (KOA) in comparison with usual care. [Subjects and Methods] Five databases were systematically searched for relevant randomised controlled trials (RCTs) according to the selected eligibility criteria (inception to June 7, 2016). PEDro scale was used to assess the validity of included studies. [Results] Four studies met the inclusion criteria and all studies had high methodological quality. The total number of participants was 665 across the four included studies. All participants had been diagnosed with KOA (clinical and radiographic evaluation). The majority of the population were female (71.13%). The interventions utilised were: CBT, CBT for insomnia (CBT-I), PCST, and PCST combined with behavioral weight management (BWM) in one study and with exercise in another study. The outcome measure for pain in KOA was the WOMAC scale. Overall, three studies have reported clinical improvement in KOA pain perception after 12-month follow-up time point. [Conclusion] This review has recognised the need for future studies that have rigorous methodological quality, and investigate the effect of mutual CBT and PCST protocols on KOA pain and pain-related functional and psychological abilities.

Biopsychosocial factors associated with chronic low back pain disability in rural Nigeria: a population-based cross-sectional study

Introduction

Many people in Nigeria are living with disability due to chronic low back pain (CLBP), with the greatest burden accounted for by people living in rural Nigeria. However, factors associated with disability in rural Nigeria have not yet been established. We investigated the biomechanical and psychosocial predictors of CLBP disability in a rural Nigerian population.

Methods

A cross-sectional study of adults with non-specific CLBP recruited from rural communities in Enugu State, South-eastern Nigeria. Measures of self-reported and performance-based disability, pain intensity, anxiety and depression, coping strategies, social support, occupational biomechanical factors, illness perceptions and fear avoidance beliefs were collected by trained community health workers. We used univariate and multivariate analyses.

Results

200 individuals were recruited. Psychosocial factors were the most important factors associated with CLBP disability, and accounted for 62.5% and 49.1% of the variance in self-reported and performance-based disability, respectively. The significant predictors of self-reported disability were: illness perceptions (β=0.289; p<0.0005), pain intensity (β=0.230; p<0.0005), catastrophising (β=0.210; p=0.001), fear avoidance beliefs (β=0.198; p=0.001) and anxiety (β=0.154; p=0.023). The significant predictors of performance-based disability were: illness perceptions (β=0.366; p<0.0005), social support (β=0.290; p<0.0005), fear avoidance beliefs (β=0.189; p<0.01) and female gender (β=0.184; p<0.01). Illness concern was the most salient dimension of illness perceptions predicting self-reported and performance-based disability.

Conclusions

These results provide evidence which can be used to inform the development of interventions to reduce CLBP disability in rural Nigeria, and may have relevance in other rural African contexts.

A randomized controlled trial on the long-term effects of proprioceptive neuromuscular facilitation training, on pain-related outcomes and back muscle activity, in patients with chronic low back pain

BACKGROUND

The role of exercise therapy in improving pain-related clinical outcomes and trunk muscle activity in patients with chronic low back pain (CLBP) has been widely reported. There is little information on the effect of proprioceptive neuromuscular facilitation (PNF) training in patients with CLBP. The purpose of the present study was therefore to investigate the persistence of the effects of PNF training on pain intensity, functional disability, patient satisfaction, health-related quality of life (HRQOL) and lower back muscle activity in patients with CLBP.

METHODS

Forty-two participants with CLBP were randomly assigned either to 4-week PNF training or to a control group receiving a Low back pain educational booklet. Pain-related outcomes, including pain intensity, functional disability, patient satisfaction, HRQOL and lumbar erector spinae (LES) muscle activity, were measured before and after the intervention, and at a follow-up session 12 weeks after the last intervention session.

RESULTS

Compared with the control group, after undergoing a 4-week PNF training intervention, participants showed a significant reduction in pain intensity and functional disability, and improved patient satisfaction and HRQOL (p < 0.01). These effects were still significant at the 12-week follow-up assessment (p < 0.01). LES muscle activity in the PNF training group was significantly increased throughout the measurement periods compared with controls (p < 0.01).

CONCLUSIONS

The study found that 4-week PNF training has positive long-term effects on pain-related outcomes, and increases lower back muscle activity in patients with CLBP.

Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain

BACKGROUND

Cognitive functional therapy (CFT) has been shown to reduce pain and disability in people with chronic low back pain.

OBJECTIVES

The purpose of this study was to investigate participants' experience of CFT by comparing participants who reported differing levels of improvement after participation in CFT, potentially yielding insight into the implementation of this approach.

DESIGN

This was a noninterventional, cross-sectional, qualitative study with an interpretive description framework.

METHODS

Individuals who had participated in CFT in 2 physical therapy settings (in Ireland and Australia) were recruited through purposive sampling based on disability outcomes postintervention (n=9), and theoretical sampling (n=5). This sampling strategy was used to capture a range of participant experiences but was not used to define the final qualitative groupings. Semistructured interviews were conducted 3 to 6 months postintervention.

RESULTS

Three groups emerged from the qualitative analysis: large improvers, small improvers, and unchanged. Two themes encapsulating the key requirements in achieving a successful outcome through CFT were identified: (1) changing pain beliefs and (2) achieving independence. Changing pain beliefs to a more biopsychosocial perspective required a strong therapeutic alliance, development of body awareness, and the experience of control over pain. Independence was achieved by large improvers through newly cultivated problem-solving skills, self-efficacy, decreased fear of pain, and improved stress coping. Residual fear and poor stress coping meant that small improvers were easily distressed and lacked independence. Those who were unchanged continued to feel defined by their pain and retained a biomedical perspective.

CONCLUSIONS

A successful outcome after CFT is dependent on instilling biopsychosocial pain beliefs and developing independence among participants. Small improvers may require ongoing support to maintain results. Further study is needed to elucidate the optimal approach for those who were unchanged.

Translation, cross-cultural adaptation and psychometric properties of the Back Beliefs Questionnaire in Modern Standard Arabic

Purpose To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) into modern standard Arabic and examine its validity, acceptability and reliability in Arabic-speaking patients with low back pain (LBP). Method The BBQ was forward, back-translated and reviewed by an expert committee. Seventeen bilingual patients completed Arabic and English BBQs. LBP patients (n = 199) completed the Arabic BBQ. Sixty-four repeated it a week later, and 151 completed the Arabic Fear-avoidance Beliefs Questionnaire (FABQ). Results The expert committee followed advice from the developers to maintain Arabic equivalence of "back trouble(s)". Patients found the questionnaire comprehensible and acceptable. Agreement between the English and Arabic versions of the BBQ was acceptable, ICC =  0.65 (0.25-0.86). Most item-by-item agreement ranged from fair to moderate (K = 0.12-0.54). Mean (SD) of BBQ, FABQ total, work and physical activity subscales were 25.31(6.13), 44.76(19.49), 21.17(10.10) and 13.95(6.65). The BBQ correlated with the FABQ at r = -0.33, work subscale r = -0.29 and physical activity r = -0.30 (all p < 0.01). Cronbach's α = 0.73 indicated high internal consistency. Test-retest reliability was high, ICC = 0.80 (0.68-0.87). Item-by-item agreement ranged from fair to acceptable (K = 0.31-0.66). Conclusions The Arabic BBQ has good comprehensibility and acceptability, acceptable agreement with the English BBQ, high internal consistency and test-retest reliability. We recommend its use with Arabic-speaking LBP patient to determine their beliefs and attitudes about their back pain, as they have been shown to be important predictors of persistent LBP disability. Implications for Rehabilitation There are limited valid and reliable outcome measures for back pain in Arabic. The Back Beliefs Questionnaire (BBQ) is a tool that measures attitudes and beliefs about back pain. We recommend the use of our valid and reliable, translated and cross-culturally adapted tool with Arabic-speaking patients. The tool can measure attitudes and beliefs concerning the future consequences of LBP, with regards to recovery and return to work in this sample. Findings will improve back pain management options aimed at reducing back pain disability though challenging and modifying beliefs in the Middle East or with migrant populations in the West.

Symptoms of depression as a prognostic factor for low back pain: a systematic review

BACKGROUND CONTEXT

It has been proposed that depression plays an important role in the course of low back pain; however, there is considerable uncertainty on its predictive value.

PURPOSE

This systematic review aims to investigate the effect of depression on the course of acute and subacute low back pain.

STUDY DESIGN

This is a systematic review.

METHODS

We searched the following databases using optimized search strategies: AMED, CINAHL, EMBASE, Health & Society Database, LILACS, MEDLINE, PsycINFO, Scopus, and Web of Science. We only included prospective studies that investigated a cohort of participants with acute or subacute non-specific low back pain (pain of less than 12 weeks' duration). The prognostic factor of interest was depression or symptoms of depression assessed at baseline. The outcomes of interest included pain intensity, chronicity (non-recovery from low back pain), disability, return to work, health-related quality of life, and overall patient satisfaction. Two independent reviewers selected the studies, extracted the data, and assessed the methodological quality of the studies that were included.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest-associated biases.

RESULTS

Seventeen articles reporting 13 cohort studies were included in this review. There was considerable variability between studies in terms of the method of assessment of depression and low back pain, statistical methods, and follow-up length, which precluded the quantitative synthesis of the results. Definition of outcomes varied across studies, but overall they could be divided into work-related outcome measures, followed by disability, pain, self-perceived recovery, and mixed outcomes. Eleven out of 17 articles (or 8 out of 13 cohorts) reported that symptoms of depression at baseline are related to worse low back pain outcomes (measured in various ways) at follow-up, and the effect sizes (odds ratio [OR]) ranged from 1.04 to 2.47. Only two studies that did not find a statistically significant association reported quantitative results: OR=1.03, 95% confidence interval (CI) 0.98-1.08; and OR=1.02, 95% CI 0.99-1.06. All included studies, regardless of statistical significance, showed an effect in the direction of harm.

CONCLUSIONS

Although a definitive answer on the effect of depression on the course of low back pain is not available, the findings of this systematic review suggest that depression might have an adverse effect on the prognosis of low back pain. Future large studies that enroll an inception cohort and that employ a standardized method for assessing depression and low back pain are needed.

Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care

Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care. In the first systematic review, the patients' or HCPs' overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome, with predictive validity similar to that of multidimensional scales. This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view. The second review showed that most of the interventions targeting psychosocial factors in LBP in primary care have to date focused on the cognitive-behavioral factors, resulting in little impact. It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients; interventions targeting determinants from several fields (mainly psychosocial, biomechanical, and occupational) may be more relevant. Should multiple stakeholders be involved in such interventions, enhanced interprofessional collaboration would be critical to ensure the delivery of coordinated care. Finally, in the third study, the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care. Rather than specifically screening for psychosocial conditions, this suggests taking into account any potential comorbidity in patients with chronic LBP, as in other patients. All these results support the adoption of a more comprehensive and patient-centered approach when dealing with patients with LBP in primary care. As this condition is illustrative of many situations encountered in primary care, the strategies proposed here may benefit most patients consulting in this setting.

Pathomechanisms of discogenic low back pain in humans and animal models

BACKGROUND CONTEXT

Although explored in humans and animal models, the pathomechanisms of discogenic low back pain (LBP) remain unknown.

PURPOSE

The aim of this study was to review the literature about the pathomechanisms of discogenic LBP.

METHODS

Animal models of discogenic pain and specimens from degenerated human intervertebral discs (IVDs) have provided clues about the pathomechanisms of discogenic LBP. Painful discs are characterized by a confluence of innervation, inflammation, and mechanical hypermobility. These three possible mechanisms are discussed in this review.

RESULTS

Animal models and specimens from humans have revealed sensory innervation of lumbar IVDs and sensory nerve ingrowth into the inner layer of IVDs. Cytokines such as tumor necrosis factor-α and interleukins induce this ingrowth. Nerve growth factor has also been recently identified as an inducer of ingrowth. Finally, disc degeneration induces several collagenases; their action results in hypermobility and pain.

CONCLUSIONS

To treat discogenic LBP, it is important to prevent sensitization of sensory nerve fibers innervating the IVD, to suppress pathogenic increases of cytokines, and to decrease disc hypermobility.

Cross-cultural translation, adaptation, and psychometric testing of the Roland-Morris disability questionnaire into modern standard Arabic

STUDY DESIGN

Cross-cultural translation, adaptation, and psychometric testing.

OBJECTIVE

To cross-culturally translate and adapt the Roland-Morris Disability Questionnaire (RMDQ) into Modern Standard Arabic and examine its validity with Arabic-speaking patients with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The English RMDQ is valid, reliable, and commonly used to assess LBP disability in clinical practice and research. There is no valid and reliable version of the RMDQ in Modern Standard Arabic.

METHODS

The RMDQ was forward translated and back translated. An expert committee of musculoskeletal physiotherapists reviewed the translation. Eight patients with LBP evaluated item-by-item comprehensibility. Ten patients piloted the RMDQ for overall comprehensibility and acceptability. Seventeen bilingual patients tested the agreement of the Arabic and English RMDQs. Two-hundred one patients completed the RMDQ and the visual analogue scale. Sixty-four patients were followed-up for test-retest reliability.

RESULTS

Translation of most items was uncontroversial. The expert committee found the Arabic RMDQ clinically and culturally appropriate. They reviewed item 11, addressing bending and kneeling, because this has a clinical significance and cultural/religious implication regarding prayer positions. All patients reported that it was easy to understand and complete. The Arabic RMDQ had high overall agreement with the English RMDQ for the global score (intraclass correlation coefficient [ICC] = 0.925; 0.811-0.972). Kappa statistics showed good item-by-item agreement (none ≤0.30). Mean (SD) RMDQ and visual analog scale scores of 201 patients were 10.53 (4.80) and 5.11 (2.28), respectively. The RMDQ had a low correlation against pain intensity (r = 0.259; P < 0.01). A Cronbach α of 0.729 showed high internal consistency. Test-retest reliability of the Arabic RMDQ was good (ICC = 0.900; 95% confidence interval, 0.753-0.951). Kappa statistics were high for 18 items and fair for 6.

CONCLUSION

The Arabic version of the RMDQ has good comprehensibility and acceptability, high internal consistency and reliability, low correlation against pain intensity, and good agreement with the English RMDQ. We recommend its use with Arabic-speaking patients with LBP.

LEVEL OF EVIDENCE

3.

The Nijmegen decision tool for chronic low back pain. Development of a clinical decision tool for secondary or tertiary spine care specialists

BACKGROUND

In Western Europe, low back pain has the greatest burden of all diseases. When back pain persists, different medical specialists are involved and a lack of consensus exists among these specialists for medical decision-making in Chronic Low Back Pain (CLBP).

OBJECTIVE

To develop a decision tool for secondary or tertiary spine care specialists to decide which patients with CLBP should be seen by a spine surgeon or by other non-surgical medical specialists.

METHODS

A Delphi study was performed to identify indicators predicting the outcome of interventions. In the preparatory stage evidence from international guidelines and literature were summarized. Eligible studies were reviews and longitudinal studies. Inclusion criteria: surgical or non-surgical interventions and persistence of complaints, CLBP-patients aged 18-65 years, reported baseline measures of predictive indicators, and one or more reported outcomes had to assess functional status, quality of life, pain intensity, employment status or a composite score. Subsequently, a three-round Delphi procedure, to reach consensus on candidate indicators, was performed among a multidisciplinary panel of 29 CLBP-professionals (>five years CLBP-experience). The pre-set threshold for general agreement was ≥70%. The final indicator set was used to develop a clinical decision tool.

RESULTS

A draft list with 53 candidate indicators (38 with conclusive evidence and 15 with inconclusive evidence) was included for the Delphi study. Consensus was reached to include 47 indicators. A first version of the decision tool was developed, consisting of a web-based screening questionnaire and a provisional decision algorithm.

CONCLUSIONS

This is the first clinical decision tool based on current scientific evidence and formal multidisciplinary consensus that helps referring the patient for consultation to a spine surgeon or a non-surgical spine care specialist. We expect that this tool considerably helps in clinical decision-making spine care, thereby improving efficient use of scarce sources and the outcomes of spinal interventions.

Interventions focusing on psychosocial risk factors for patients with non-chronic low back pain in primary care--a systematic review

BACKGROUND

Low back pain (LBP) is a problem that is frequently encountered in primary care, and current guidelines encourage care providers to take into account psychosocial risk factors in order to avoid transition from acute to chronic LBP.

OBJECTIVE

To review the effectiveness of interventions focusing on psychosocial risk factors for patients with non-chronic LBP in primary care.

METHODS

A systematic search was undertaken for controlled trials focusing on psychosocial factors in adult patients with non-chronic, non-specific LBP in primary care by exploring Medline, Embase, PsycInfo, Francis, Web of Sciences and The Cochrane Library. The methodological quality of the studies included was assessed before analysing their findings.

RESULTS

Thirteen studies were selected, seven being considered as having a low risk of bias. Information strategies were assessed by eight trials, with high-quality evidence of no effectiveness for pain, function, work issues and health care use, low-quality evidence of no effectiveness for self-rated overall improvement, satisfaction and pain beliefs and lack of evidence in terms of quality of life. Cognitive behavioural therapy was assessed by three trials, with very low-quality evidence of moderate effectiveness for pain, function, quality of life, work issues and health care use. There was lack of evidence concerning the effectiveness of individual and group education intervention or work coordination.

CONCLUSION

Among the wide range of psychosocial risk factors, research has focused mainly on pain beliefs and coping skills, with disappointing results. Extended theoretical models integrating several psychosocial factors and multicomponent interventions are probably required to meet the challenge of LBP.

Do analgesics improve functioning in patients with chronic low back pain? An explorative triple-blinded RCT

PURPOSE

TREATMENT of patients with chronic low back pain (CLBP) aims to reduce disability, improve functional capacity, and participation. Time contingent prescription of analgesics is a treatment modality in CLBP. The impact of analgesics on functional capacity is unknown. Aim of the study was to explore the effect of analgesics on functioning measured by functional capacity evaluation, and self-reported disability in patients with CLBP.

METHODS

Explorative Randomized Placebo-Controlled Clinical Trial was performed in an outpatient pain rehabilitation setting on patients waiting for rehabilitation. Included patients had low back pain lasting >3 months, visual analogue scale worst pain ≥4.0 cm, and age >18 years. Outcome measures before (T0) and after treatment (T1): functional capacity, pain intensity, Roland Morris Disability Questionnaire. T1: global perceived pain relief. Patient characteristics and psychological questionnaires were assessed. Fifty patients were included in this study and were randomly assigned to 2 weeks treatment or placebo.

TREATMENT

acetaminophen/tramadol 325 mg/37.5 mg per capsule. Dose: maximum acetaminophen 1,950 mg and tramadol 225 mg per day; treatment and placebo titrated identically. Compliance and side-effects were monitored. TREATMENT effects between groups over time were compared.

RESULTS

One patient (treatment group) was lost to follow-up. Forty-nine patients remained in the study. TREATMENT effects in primary outcomes did not differ significantly between groups. A subgroup of 10 (42%) patients (treatment group) reported global pain relief (responders) who reduced self-reported disability (p < 0.05). Responders had significantly lower catastrophizing scores.

CONCLUSION

Overall treatment effects were small and non-significant. A subgroup, however, reported improved functioning as a result of treatment. Responders had lower catastrophizing scores.

Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychological programme for chronic low back pain

PURPOSE

The aim of this longitudinal study is to determine the factors which predict a successful 1-year outcome from an intensive combined physical and psychological (CPP) programme in chronic low back pain (CLBP) patients.

METHODS

A prospective cohort of 524 selected consecutive CLBP patients was followed. Potential predictive factors included demographic characteristics, disability, pain and cognitive behavioural factors as measured at pre-treatment assessment. The primary outcome measure was the oswestry disability index (ODI). A successful 1-year follow-up outcome was defined as a functional status equivalent to 'normal' and healthy populations (ODI ≤22). The 2-week residential programme fulfills the recommendations in international guidelines. For statistical analysis we divided the database into two equal samples. A random sample was used to develop a prediction model with multivariate logistic regression. The remaining cases were used to validate this model.

RESULTS

The final predictive model suggested being 'in employment' at pre-treatment [OR 3.61 (95 % CI 1.80-7.26)] and an initial 'disability score' [OR 0.94 (95 % CI 0.92-0.97)] as significant predictive factors for a successful 1-year outcome (R (2) = 22 %; 67 % correctly classified). There was no predictive value from measures of psychological distress.

CONCLUSION

CLBP patients who are in work and mild to moderately disabled at the start of a CPP programme are most likely to benefit from it and to have a successful treatment outcome. In these patients, the disability score falls to values seen in healthy populations. This small set of factors is easily identified, allowing selection for programme entry and triage to alternative treatment regimes.

Introducing the bio-psycho-social-physical model of dementia through a collective case study design

AIMS AND OBJECTIVES

To provide evidence for the development of a physical domain attached to the well-known bio-psycho-social model of dementia. The objectives were to develop a set of international case studies that followed a trajectory approach, from prevention to end-of-life care.

BACKGROUND

In the UK the bio-psycho-social model has informed the shape of the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence 'dementia' guideline. However, limited attention has been paid to outlining and describing a physical domain of dementia, a discrepancy that informed the rationale for this study.

DESIGN

A collective case study design was used to address the research aim and objectives.

METHODS

Case studies from along the trajectory of dementia were provided by an international team of contributors from an inter-disciplinary background comprising nursing (general and mental health), social work and social science.

RESULTS

The team's synthesis and analysis of the six case studies generated five repeating themes with each theme becoming components of a 'physical' domain of dementia. The five identified physical components were: (1) physical well-being, (2) physical health and examination, (3) physical care, (4) physical treatment and (5) physical environment.

CONCLUSIONS

The development of a bio-psycho-social-physical model of dementia presents a holistic and culturally sensitive approach to understanding the experience of living with dementia, and to providing care and support in a variety of situations and contexts.

RELEVANCE TO CLINICAL PRACTICE

The physical domain of dementia has particular relevance to nursing and nursing practice, such as providing physical care at the end-of-life. The interplay between the biological-psychological-social-physical domains of dementia and the trajectory of dementia could form the basis of clinical decision-making and practice.

Pain and pain-related fear are associated with functional and social disability in an occupational setting: Evidence of mediation by pain-related fear

This study examined the role of work-related, psychosocial and psychological factors in predicting functional and social disability in working employees. In a cross-sectional design, 890 working employees (reporting at least 1 day of back pain during the past year) completed self-report measures of back pain, disability, pain-related fear, negative and positive affectivity, job satisfaction, job stress and physical work load. Regression analyses revealed that pain intensity was a strong predictor of functional (beta = .69, p < .001) and social disability (beta = .67, p < .001). Fear of (re)injury due to movement (beta = .25, p < .001; beta = .28, p < .001) had additional predictive value in both models. Further, (singular) mediation tests indicated that fear for (re)injury partially mediated the relation between pain intensity and disability, and between negative affectivity and disability. Finally, path analyses revealed both fear and pain intensity as mediators between negative affectivity and disability. Overall, our findings point at the relevance of the cognitive-behavioral model of avoidance in occupational settings.

Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain

Low back pain (LBP) is a major health issue with significant socioeconomic implications in most Western countries. Many forms of treatment have been proposed and investigated in the past, with exercise being a commonly prescribed intervention. Within allied health, in particular physiotherapy, there has been a growing movement that recognizes the role of the McKenzie method in treating LBP. Within the McKenzie framework, directional preference (DP) exercises are one such intervention, with preliminary data demonstrating its effectiveness in the management of LBP. In this paper, we aim to integrate the evidence from current research, identified using a systematic review, and utilize a practical real-life case scenario to outline how evidence from the literature can be implemented in clinical practice. The findings from the systematic review indicate that DP exercises may have positive effects in the management of LBP. While the body of evidence to support this is limited (only four studies) and therefore modest at best, it does provide some emerging evidence to support the use of DP exercises in clinical practice. Despite this, gaps also persist in the literature on DP exercises, and this relates to the exercise parameters and the compliance rates. Recognizing this dichotomy (modest evidence in some areas and evidence gaps in other areas), which is likely to confront health practitioners, using a practical approach with a real-life clinical scenario, we outline how the evidence from the systematic review can be implemented in clinical practice. This approach builds on the philosophy of evidence-based practice of integrating research evidence with clinical expertise and patient values.

Prognostic factors in non-surgically treated sciatica: a systematic review

Background

When present sciatica is considered an obstacle to recovery in low back pain patients, yet evidence is limited regarding prognostic factors for persistent disability in this patient group. The aim of this study is to describe and summarise the evidence regarding prognostic factors for sciatica in non-surgically treated cohorts. Understanding the prognostic factors in sciatica and their relative importance may allow the identification of patients with particular risk factors who might benefit from early or specific types of treatment in order to optimise outcome.

Methods

A systematic literature search was conducted using Medline, EMBASE and CINAHL electronic databases. Prospective cohort studies describing subjects with sciatica and measuring pain, disability or recovery outcomes were included. Studies of cohorts comprised entirely of surgically treated patients were excluded and mixed surgically and conservatively treated cohorts were included only if the results were analysed separately by treatment group or if the analysis was adjusted for treatment.

Results

Seven adequate or high quality eligible studies were identified. There were conflicting but mainly negative results regarding the influence of baseline pain severity, neurological deficit, nerve root tension signs, duration of symptoms and radiological findings on outcome. A number of factors including age, gender, smoking, previous history of sciatica and heaviness of work do not appear to influence outcome. In contrast to studies of low back pain and purely surgically treated sciatica cohorts, psychological factors were rarely investigated.

Conclusions

At present, the heterogeneity of the available studies makes it difficult to draw firm conclusions about sciatica prognosis, and highlights the need for further research for this group of patients. Large scale prospective studies of high methodological quality, using a well-defined, consistent definition of sciatica and investigating psychosocial factors alongside clinical and radiological findings are recommended to identify prognostic factors in this population.

Contribution of chronic disease to the burden of disability

Background

Population ageing is expected to lead to strong increases in the number of persons with one or more disabilities, which may result in substantial declines in the quality of life. To reduce the burden of disability and to prevent concomitant declines in the quality of life, one of the first steps is to establish which diseases contribute most to the burden. Therefore, this paper aims to determine the contribution of specific diseases to the prevalence of disability and to years lived with disability, and to assess whether large contributions are due to a high disease prevalence or a high disabling impact.

Methodology/Principal Findings

Data from the Dutch POLS-survey (Permanent Onderzoek Leefsituatie, 2001–2007) were analyzed. Using additive regression and accounting for co-morbidity, the disabling impact of selected chronic diseases was calculated, and the prevalence and years lived with ADL and mobility disabilities were partitioned into contributions of specific disease. Musculoskeletal and cardiovascular disease contributed most to the burden of disability, but chronic non-specific lung disease (males) and diabetes (females) also contributed much. Within the musculoskeletal and cardiovascular disease groups, back pain, peripheral vascular disease and stroke contributed particularly by their high disabling impact. Arthritis and heart disease were less disabling but contributed substantially because of their high prevalence. The disabling impact of diseases was particularly high among persons older than 80.

Conclusions/Significance

To reduce the burden of disability, the extent diseases such as back pain, peripheral vascular disease and stroke lead to disability should be reduced, particularly among the oldest old. But also moderately disabling diseases with a high prevalence, such as arthritis and heart disease, should be targeted.

Emotional and neurobehavioural status in chronic pain patients

OBJECTIVE

To investigate the emotional and neurobehavioural status of patients suffering from chronic pain.

METHODS

Fifteen male patients with chronic lower back pain and 15 healthy control subjects were studied for approximately six months. Pain was measured using a visual analogue scale. The WHO Neurobehavioral Core Test Battery (NCTB) was used to assess neurobehavioural effects of environmental and occupational exposures.

RESULTS

Visual analogue scale results demonstrated a modest range of reported pain (mean [± SD] 62.0 ± 10.8) in chronic pain patients, whereas control subjects reported no measurable pain. With the NCTB, it was found that scores of negative mood state, including anger-hostility, depression-dejection, fatigue-inertia and tension-anxiety in pain patients were significantly higher than scores in the control subjects. By contrast, scores of positive mood state (vigour-activity) in chronic pain patients were lower than those in the control group. The NCTB scores of the Santa Ana Dexterity and Pursuit Aiming II tests in chronic lower back pain patients were lower than those of the control group. Scores for other NCTB subtests, including the Digit Span, Benton Visual Retention and Digit Symbol tests, were not significantly different compared with controls. <span style="font-weight:

CONCLUSIONS

Chronic lower back pain patients had more negative mood and less positive mood than controls. These patients also demonstrated neuromotor deficits in coordination and reaction time. Further studies are required to examine possible neurological mechanisms and research potential intervention strategies for patients suffering from chronic pain.

Rehabilitation outcomes for orthopaedic trauma individuals as measured by the INTERMED

PURPOSE

Bio-psychosocial characteristics of patients after orthopaedic traumas may be a strong predictor of poor outcome. The objective of this prospective study was to assess whether the INTERMED, a measure of bio-psychosocial complexity, identifies complex inpatients during rehabilitation including vocational aspects with a poor outcome 1 year after discharge.

METHOD

At entry, the INTERMED scores of 118 inpatients were used to assign patients to the high or low complexity group. A questionnaire evaluated 1 year after discharge whether patients: (1) returned to work, (2) still have therapies, (3) take psychoactive drugs, (4) take medication against pain and (5) were satisfied with vocational therapy. Univariate logistic regressions identified which variables predict INTERMED case complexity during hospitalisation as well as predictors (i.e. INTERMED case complexity, French as preferred language, duration of the disability, accident at work, work qualification, severity of the injury, psychiatric co-morbidities, pain) of the five measured outcomes 1 year after discharge.

RESULTS

During hospitalisation, the high complexity group was associated with a high prevalence of psychiatric co-morbidities, a higher level of pain and a weaker perception of treatment effects. One year after discharge, the INTERMED was the sole variable to predict all outcomes.

CONCLUSION

The INTERMED identifies complex patients during vocational rehabilitation after orthopaedic trauma and is a good predictor of poor outcome 1 year after discharge.

Psychosocial influences on low back pain, disability, and response to treatment

Evidence suggests that psychosocial factors have an influence on the outcome of physical therapy treatment and that the extent of their influence differs considerably among patients. As a consequence, substantial research efforts are focused on developing new clinical tools designed to identify and highlight when psychosocial factors are present at a level relevant to decision making. The conceptual differences in the ways that psychosocial factors influence outcome are described, structured around 3 common research terms: (1) prognostic factors, (2) treatment effect modifiers or moderators, and (3) treatment mediators. Prognostic factors are those characteristics that help estimate a patient's likely outcome irrespective of the chosen management. Treatment effect modifiers or moderators are factors measured at baseline that influence the relationship between a specific intervention and outcome. Treatment mediators are factors that have an intermediary role in the link between treatment and outcome. How these different influences on outcome can be translated into useful and complementary tools that aim to reduce treatment variability in clinical practice is described. One approach is to use prognostic factors to develop screening tools that identify an individual's risk status, typically based on predictive psychosocial factors such as catastophizing and depression. Another approach is to identify specific treatment effect modifiers to derive treatment decision aids or prediction rules to help match a patient's characteristics to the interventions available. A third approach is to use treatment mediators (eg, self-efficacy) to develop monitoring tools to inform the clinician about which aspects of treatment to strengthen.