Altering beliefs about pain and impairment in a functionally oriented treatment program for chronic low back pain

Association Between Depressive Symptoms or Depression and Health Outcomes for Low Back Pain: a Systematic Review and Meta-analysis

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).

Predicting treatment adherence and outcome to outpatient multimodal rehabilitation in chronic low back pain

BACKGROUND

There is a growing need to identify patient pre-treatment characteristics that could predict adherence and outcome following specific interventions.

OBJECTIVE

To identify predictors of adherence and outcome to outpatient multimodal rehabilitation in chronic low back pain (CLBP).

METHODS

A total of 273 CLBP patients participated in an exercise-based rehabilitation program. Patients who completed ⩾ 70% of the treatment course were classified as adherent. Patients showing a post-treatment reduction of ⩾ 30% in Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) back pain intensity scores were assigned to the favorable outcome group.

RESULTS

Multivariate logistic regression revealed that higher age, higher ability to perform low-load activities, and higher degrees of kinesiophobia increased the odds to complete the rehabilitation program. By contrast, lower levels of education and back pain unrelated to poor posture increased the odds for non-adherence. Furthermore, a favorable outcome was predicted in case the cause for LBP was known, shorter symptom duration, no pain in the lower legs, no difficulties falling asleep, and short-term work absenteeism.

CONCLUSIONS

Assessment and consideration of patient pre-treatment characteristics is of great importance as they may enable therapists to identify patients with a good prognosis or at risk for non-responding to outpatient multimodal rehabilitation.

Early termination in interdisciplinary pain rehabilitation: numbers, timing, and reasons. A mixed method study

PURPOSE

To analyse the number of, timing of, and reasons for early termination of interdisciplinary pain rehabilitation (IPR).

METHODS

A multicentre study in two Dutch rehabilitation centres with a mixed method design. Quantitative part: retrospective patient file review of all IPR patients. Qualitative part: 20 semi-structured patient interviews with early IPR terminators.

RESULTS

One hundred and thirty-seven of 428 participants (31.3%) had terminated IPR early, of which almost 30% had a positive reason. Of a planned treatment duration of 12 weeks, the median (interquartile range (IQR)) reduction was 5.3 week (3.0; 8.0). Over 80% of the early terminators with negative reasons stopped in the first half of IPR, whereas approximately 55% of the early terminators with positive reasons stopped in the final quarter of IPR. A discrepancy between patient expectations of the aim and content and the actual IPR was mentioned as a negative reason for early termination. Many of the positive early terminators were able to self-manage.

CONCLUSIONS

Previously reported figures on early termination were confirmed. Early termination of IPR should not be considered negative per se, because a substantial proportion of early terminations have a positive reason. Negative early terminators tend to stop earlier during IPR, compared to positive terminators.Implications for rehabilitationSubstantial rates of patients (31%) terminate interdisciplinary pain rehabilitation (IPR) earlier than planned.Early IPR termination should not be considered negative per se, because a substantial proportion of early terminations have a positive reason (i.e. goals achieved early).Although patients receive extensive personalised information about aim and content of IPR before starting, early terminators with a negative reason often have different expectations about the aim and content of treatment.Clinicians and researchers should be focused on how to explain IPR to the patient and check whether the patient has understood it well and is convinced of its credibility.

Dutch Translation and Adaptation of the Treatment Beliefs Questionnaire for Chronic Pain Rehabilitation

Background

The Treatment Beliefs Questionnaire has been developed to measure patients' beliefs of necessity of and concerns about rehabilitation. Preliminary evidence suggests that these beliefs may be associated with attendance of rehabilitation. The aim of this study was to translate and adapt the Treatment Beliefs Questionnaire for interdisciplinary pain rehabilitation and to examine the measurement properties of the Dutch translation including the predictive validity for dropout.

Methods

The questionnaire was translated in 4 steps: forward translation from English into Dutch, achieving consensus, back translation into English, and pretesting on providers and patients. In order to establish structural validity, internal consistency, construct validity, and predictive validity of the questionnaire, 188 participants referred to a rehabilitation centre for outpatient interdisciplinary pain rehabilitation completed the questionnaire at the baseline. Dropout was measured as the number of patients starting, but not completing the programme. For reproducibility, 51 participants were recruited at another rehabilitation centre to complete the questionnaire at the baseline and one week later.

Results

We confirmed the structural validity of the Treatment beliefs Questionnaire in the Dutch translation with three subscales, necessity, concerns, and perceived barriers. internal consistency was acceptable with ordinal alphas ranging from 0.66–0.87. Reproducibility was acceptable with ICC_{2,1 agreement} ranging from 0.67–0.81. Hypotheses testing confirmed construct validity, similar to the original questionnaire. Predictive validity showed the questionnaire was unable to predict dropouts.

Conclusion

Cross-cultural translation was successfully completed, and the Dutch Treatment Beliefs Questionnaire demonstrates similar psychometric properties as the original English version.

The influence of an educational internet-based intervention in the beliefs and attitudes of primary care professionals on non-specific chronic low back pain: study protocol of a mixed methods approach

BACKGROUND

Personal convictions in referral to pain cause misbeliefs in health professionals, which can influence patients who suffer from non-specific chronic low back pain. Likewise, health professionals' beliefs affect their advice and attitudes towards patients' treatment, becoming a possible cause of greater disability. The development of educational interventions based on the best scientific evidence in neurophysiology of pain could be a way to provide information and advice to primary care health professionals to change their cognition towards chronic non-specific low back pain. The use of Information and Communication Technologies allows the development of web sites, which might be one of the effective resources to modify misbeliefs and attitudes, in relation to the origin and meaning of non-specific chronic low back pain, of primary care professionals and that may modify their attitudes in patients' treatment.

METHODS

The aim of this project is to identify misbeliefs and attitudes of primary care physicians and nurses about chronic non-specific low back pain to develop a web-based educational tool using different educational formats and gamification techniques. This study has a mixed-method sequential exploratory design. The participants are medical and nursing staff working in primary care centers in the city of Lleida, Spain. For the qualitative phase of this study, the authors will use personal semi-structured interviews. For the quantitative phase the authors will use an experimental study design. Subjects will be randomly allocated using a simple random sample technique. The intervention group will have access to the web site where they will find information related to non-specific chronic low back pain, based on the information obtained in the qualitative phase. The control group will have access to a video explaining the clinical practice guidelines on low back pain.

DISCUSSION

This study has been designed to explore and modify the beliefs and attitudes about chronic low back pain of physicians and nurses working in primary care settings, using a web-based educational tool with different educational formats and gamification techniques. The aim of the educational intervention is to change their knowledge about the origin and meaning of pain, with the result of reducing their misbeliefs and attitudes of fear avoidance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02962817 . Date of registration: 11/09/2016.

Psychosocial factors associated with change in pain and disability outcomes in chronic low back pain patients treated by physiotherapist: A systematic review

Background

Almost 80% of people have low back pain at least once in their life. Clinical guidelines emphasize the use of conservative physiotherapy and the importance of staying active. While the psychological factors predicting poor recovery following surgical intervention are understood, the psychosocial factors associated with poor outcomes following physiotherapy have yet to be identified.

Methods

Electronic searches of PubMed, Medline, CINAHL, PsycINFO and EBSCO were conducted using terms relating to psychosocial factors, chronic low back pain, disability and physiotherapy. Papers examining the relationship between psychosocial factors and pain and disability outcomes following physiotherapy were included. Two reviewers selected, appraised and extracted studies independently.

Results

In total, 10 observational studies were identified that suggested an association between fear of movement, depression, self-efficacy and catastrophizing in modifying pain and disability outcomes following physiotherapy.

Discussion

Although limited by methodological shortcomings of included studies, and heterogeneity of physiotherapy interventions and measures of disability and psychosocial outcomes, the findings are consistent with other research in the context of back pain and physiotherapy, which suggest an association between psychosocial factors, including fear of movement, catastrophizing and self-efficacy and pain and disability outcomes in chronic low back pain patients treated by physiotherapist. However, a direct relationship cannot be concluded from this study.

Conclusion

Findings suggest an association between psychosocial factors, including fear of movement, catastrophizing and self-efficacy and pain and disability outcomes in chronic low back pain patients treated by physiotherapist, which warrants further study.

Graded group exercise and fear avoidance behavior modification in the treatment of chronic low back pain

BACKGROUND

Approaches in the treatment of general chronic low back pain (CLBP) are multifaceted relative to specific interventions. In the past, passive interventions have commonly been employed with little evidence to support their effectiveness. Recent reviews suggest a focus on active exercises programs that includes pain education and cognitive behavioral therapy.

OBJECTIVE

To investigate the outcomes of CLBP patients and describe the approach in persons undergoing a group spinal rehabilitation program using graded exercise, and operant conditioning.

METHODS

Adult patients with CLBP participated in a twice weekly 90 minute exercise sessions for 8-weeks (n= 201). The program consisted of behavioral education, stretching, aerobic exercises, graded progressive resistance exercise, MedX isotonic strengthening, and functional bending lifting task exercises.

RESULTS

A total of 201 patient records were evaluated where the overall ODI improvement was 13.2% (± 14.0) (p< 0.001). There were significant and clinically meaningful improvements in flexibility, VAS, functional lifting tasks (p< 0.001), and lumbar extension strength (p= 0.01) at 8-week follow-up. Questionnaires were delivered via mail with a 21% return rate revealed sustained improvements.

CONCLUSION

CLBP patients undergoing an 8-week intensive exercise approach incorporating both behavioral and physical conditioning principles showed both significant and clinically significant improvements in this observational case series. Long-term benefits were also seen in both the 6 and 12 month follow-up questionnaires although further investigation is warranted due to limited survey return rate and study design.

The Relationship Between Pain Beliefs and Coping with Pain of Algology Patients'

A patient's beliefs, expectations, and attitudes about coping with pain are effective on the patient's pain control. The aim of this investigation was to evaluate the correlation between pain beliefs and coping with pain in algology patients. This descriptive study was carried out with 201 patients at a University Hospital Algology Clinic between May and July 2014. The research instruments used included a Descriptive Characteristics Data Form, Pain Beliefs Questionnaire, and Pain Coping Questionnaire. Data were evaluated by descriptive statistical methods, Spearman's correlation, and the Mann-Whitney U and Kruskal-Wallis tests. According to the findings, the duration of pain in the patients ranged from 1 month to 40 years, with a mean duration of 68.37 ± 89.42 months. Patients' organic beliefs mean score was 3.97 ± 0.78 and the psychological beliefs mean score was 5.01 ± 1.01. There was a significant negative correlation between patients' organic beliefs score and the self-management (p < .001, r = -.388) and conscious cognitive interventions scores (p < .001, r = -.331); with the helplessness score (p < .001, r = .365) there was a positive correlation. There was also a positive correlation between patients' psychological beliefs score and self-management score (p < .05, r = .162). Moreover, there is significant difference between organic beliefs score and patients who use opioid analgesic. Patients who believe that their pain's origin is a organic cause, such as damage and harm in the body, cannot cope with pain and feel more helplessness. Appropriate nursing interventions for individuals' pain beliefs should be implemented to nursing care plans on pain management.

Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial

BACKGROUND

Non-specific chronic low back pain (NSCLBP) is a major health problem. Identification of subgroups and appropriate treatment regimen was proposed as a key priority by the Cochrane Back Review Group. We developed a multimodal treatment (MMT) for patients with moderate to severe disability and medium risk of poor outcome. MMT includes a) neurophysiological education on the perception of pain to decrease self-limitation due to catastrophizing believes about the nature of NSCLBP, b) sensory training of the lower trunk because these patients predominantly show poor sensory acuity of the trunk, and c) motor training to regain definite movement control of the trunk. A pilot study was conducted to investigate the feasibility of MMT, prior to a larger RCT, with focus on patients' adherence and the evaluation of short-term effects on pain and disability of MMT when compared to usual physiotherapy.

METHOD

We conducted a randomised controlled trial (RCT) in a primary care physiotherapy centre in Switzerland. Outcome assessment was 12 weeks after baseline. Patients with NSCLBP, considerable disability (five or more points on the Roland and Morris Disability Questionnaire (RMDQ) and medium or high risk of poor outcome on the Keele Start Back Tool (KSBT) were randomly allocated to either MMT or usual physiotherapy treatment (UPT) by an independent research assistant. Treatment included up to 16 sessions over 8 to 12 weeks. Both groups were given additional home training of 10 to 30 minutes to be performed five times per week. Adherence to treatment was evaluated in order to assess the feasibility of the treatment. Assessments were conducted by an independent blinded person. The primary outcome was pain (NRS 0-10) and the secondary outcome was disability (RMDQ). Between-group effects with Student's t-test or the Mann-Whitney U test and the standardized mean difference of the primary outcome were calculated.

RESULTS

Twenty-eight patients (46% male, mean age 41.5 years (SD 10.6)) were randomized to MMT (n = 14) or UPT (n = 14). Patients' adherence to treatment was >80% in both groups. Pain reduction (NRS; [95% CI]) was 2.14 [1.0 to 3.5] in the MMT and 0.69 [-2.0 to 2.5.] in the UPT. The between-group difference was 1.45 [0.0 to 4.0] (p = 0.03), representing a moderate effect size of 0.66 [-0.1 to 1.5]. Reduction in disability on the RMDQ was 6.71 [4.2 to 9.3] in MMT and 4.69 [1.9 to 7.4] in UPT, with a non-significant between-group difference of 2.02 [-1.5 to 5.6] (p = 0.25). The required sample size for a RCT with six months follow-up was estimated at 170 patients.

CONCLUSIONS

MMT was found to be feasible and to significantly reduce pain in the short term when compared with UPT. A future RCT with a six-month follow-up would require approximately 170 patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66262199. Registered 8 January 2014.

Effects of nurse-led motivational interviewing of patients with chronic musculoskeletal pain in preparation of rehabilitation treatment (PREPARE) on societal participation, attendance level, and cost-effectiveness: study protocol for a randomized controlled trial

Background

Non-adherence and drop-out are major problems in pain rehabilitation. For patients with various health problems, motivational interviewing (MI) has shown promising effects to tackle these problems. In chronic pain patients, the effectiveness of MI is however unknown. Therefore, a MI-based pre-pain rehabilitation intervention (MIP) addressing motivation, expectations, and beliefs has been developed to prepare eligible patients for rehabilitation treatment.

Methods/design

Study design: A parallel randomized controlled trial including two interventions: a motivational interviewing pre-pain rehabilitation intervention (MIP) and a usual care (UC) control arm. Follow-up will be 6 months after completion of rehabilitation treatment.

Study population: One hundred and sixty (n = 80 per arm) patients with chronic non-specific musculoskeletal pain visiting an outpatient rehabilitation department, who are eligible to participate in an outpatient cognitive behavioral pain rehabilitation program.

Intervention: MIP consists of two sessions to prepare and motivate the patient for pain rehabilitation treatment and its bio psychosocial approach. UC consists of information and education about the etiology and the general rehabilitation approach of chronic pain. Both the MIP and UC contain two sessions of 45 to 60 minutes each.

Objective: The aim of the current study is to evaluate the effectiveness of MIP compared to UC in terms of an increase in the long-term level of societal participation and decrease of drop-out during rehabilitation treatment.

Main study endpoints: Primary outcome is the change in level of participation (according to the ICF-definition: ‘involvement in a life situation’) 6 months after completion of rehabilitation treatment. Secondary outcomes are adherence and treatment drop-out, disability, pain intensity, self-reported main complaints, (pain-specific) self-efficacy, motivation, and quality of life. Costs are calculated including the costs of the pre-treatment intervention, productivity losses, and healthcare utilization. Potential moderators and active ingredients of MI are explored. For the process evaluation, parameters such as MI fidelity, feasibility, and experiences are explored.

Discussion

The results of this study will provide evidence on the effectiveness of this MI-based pre-treatment in pain rehabilitation. Furthermore, a cost-effectiveness analysis and exploration of moderating and working mechanisms of MI and an extensive process evaluation takes place.

Trial registration

Nederlands trial register NTR3065

The Application of Cognitive—Behaviour Therapy in Altering Illness Representations of Systemic Lupus Erythematosus

There is evidence to suggest that illness representations are associated with chronic illness outcomes. Accordingly, several authors have recommended that interventions aimed at improving illness outcomes should include an illness-representations component. While a few researchers have attempted to develop such interventions for chronic illness and chronic pain, no such intervention has been developed for individuals with systemic lupus erythematosus (SLE), a chronic auto-immune illness which results in a variety of negative physical and psychological symptoms. This article reports on a pilot program that investigated the feasibility of a cognitive and behavioural—based intervention for treating SLE which included an illness-representations-change component. The effectiveness of the intervention compared to usual treatment for SLE was evaluated. Also investigated was whether changed illness representations had a beneficial effect on physical health and psychological wellbeing. It was found that the intervention did change participants' treatment control and emotional representations, and that perceived stress was reduced following the intervention. The importance of these findings is discussed, two rival hypotheses for the findings obtained are explored and directions for future research are suggested.

Fear-avoidance beliefs and pain avoidance in low back pain--translating research into clinical practice

BACKGROUND CONTEXT

For patients with low back pain, fear-avoidance beliefs (FABs) represent cognitions and emotions that underpin concerns and fears about the potential for physical activities to produce pain and further harm to the spine. Excessive FABs result in heightened disability and are an obstacle for recovery from acute, subacute, and chronic low back pain.

PURPOSE

This article summarizes past research concerning the etiology, impact, and assessment of FABs; reviews the results and relevance to clinical practice of trials that have addressed FAB as part of low back pain treatment; and lists areas in need of further study.

STUDY DESIGN

This article reports on a plenary presentation and discussion of an expert panel and workshop entitled "Addressing fear-avoidance beliefs in a fear-avoidant world--translating research into clinical practice" that was held at Forum X, Primary Care Research on Low Back Pain, during June 2009, at the Harvard School of Public Health in Boston, MA, USA.

METHODS

Important issues including the definition, etiology, impact, and treatment of FAB on low back pain outcomes were reviewed by six panelists with extensive experience in FAB-related research. This was followed by a group discussion among 40 attendees. Conclusion and recommendations were extracted by the workshop panelist and summarized in this article.

RESULTS

Fear-avoidance beliefs are derived from both emotionally based fears of pain and injury and information-based beliefs about the soundness of the spine, causes of spine degeneration, and importance of pain. Excessively elevated FABs, both in patients and treating health care providers, have a negative impact on low back pain outcomes as they delay recovery and heighten disability. Fear-avoidance beliefs may be best understood when patients are categorized into subgroups of misinformed avoiders, learned pain avoiders, and affective avoiders as these categories elucidate potential treatment strategies. These include FAB-reducing information for misinformed avoiders, pain desensitizing treatments for pain avoiders, and fear desensitization along with counseling to address the negative cognition in affective avoiders. Although mixed results have been noted, most clinical trials have documented improved outcomes when FAB is addressed as part of treatment. Deficiencies in knowledge about brief methods for assessing FAB during clinical encounters, the importance of medical explanations for back pain, usefulness of subgroup FABs, core points for information-based treatments, and efficient strategies for transferring FAB-reducing information to patients hamper the translation of FAB research into clinical practice.

CONCLUSIONS

By incorporating an understanding of FAB, clinicians may enhance their ability to assess the predicaments of their patients with low back pain and gain insight into potential value of corrective information that lessen fears and concerns on well-being of their patients.

First rehabilitation consultation in patients of non-native origin: factors that lead to tension in the patient-physician interaction

PURPOSE

To explore which factors lead to tension in the patient-physician interaction in the first consultation by rehabilitation physicians of patients with chronic non-specific low back pain of Turkish and Moroccan origin.

METHOD

In-depth semi-structured, face to face interviews were conducted with 12 patients of Moroccan and Turkish origin and four native Dutch rehabilitation physicians. Interviews were transcribed and/or summarised. All interviews were subsequently coded and analysed according to themes.

RESULTS

Factors that lead to tension in the patient-physician interaction were as follows: differences in expectations regarding the aim of treatment, symptom presentation, views on responsibilities with regard to rehabilitation treatment, lack of trust, contradicting views of physicians from patients' country of origin with regard to the cause and treatment of pain and communication problems.

CONCLUSION

Sources of tension were identified during the interaction between Dutch physicians and patients of Turkish and Moroccan origin. These factors potentially are associated with future drop-out. Future research should clarify whether these factors indeed are associated with drop-out.

Observed outcomes associated with a quota-based exercise approach on measures of kinesiophobia in patients with chronic low back pain

STUDY DESIGN

Prospective series of consecutive cases.

OBJECTIVES

To observe if kinesiophobia was altered through an education- and quota-based exercise physical therapy program, and to observe the relationship of kinesiophobia with other measures related to chronic low back pain.

BACKGROUND

The role of kinesiophobia in worsening the chronic low back pain predicament has been documented in numerous studies. However, less is known of the effect of an exerciseonly-based physical therapy program's ability to alter kinesiophobia and improve functional abilities in patients with chronic low back pain.

METHODS

Eighty-two patients with at least 3 months of low back pain, and a moderate level of disability (Oswestry score greater than or equal to 20) were willing to participate in this study. Sixty-eight of these patients completed treatment. For 68 compliant patients, females comprised 56%, the mean age was 43 years, the mean duration of symptoms was 28 months, and the primary anatomic diagnosis was disc degeneration (70%). Patients underwent a course of non-pain-contingent, quota-based physical therapy to address impairments in flexibility, strength, and lifting capacity. These were quantified prior to and following treatment using validated methods. Before and after treatment, patients completed the Fear-Avoidance Beliefs Questionnaire (FABQ), Tampa Scale of Kinesiophobia (TSK) Questionnaire, Oswestry Disability Index (ODI) Questionnaire, and a 0-to-10 visual analog scale for back and lower extremity pain. A 12-month follow-up was conducted using mailed questionnaires.

RESULTS

The mean number of physical therapy visits was 14. Clinically and statistically significant (P<.001) improvement in flexibility, strength, and lifting ability were observed. Statistically significant (P<.001) improvement in back pain, disability, and measures of kinesiophobia were also noted at discharge and maintained at 12-month follow-up. At discharge, Oswestry scores correlated with TSK (r = .59, P<.001), FABQ-Activities (r = .55, P<.001), and FABQ-Work (r = .50, P<.001) scores.

CONCLUSION

In this study we observed that kinesiophobia decreased during an intensive physical therapy program in which exercises were performed in a quota-based manner. Following the successful performance of non-pain-contingent, quota-based exercise, patients' fears of injury lessened, and this may have had a positive influence on disability.

Change Factors Explaining Reductions of “Interference” in a Multidisciplinary and an Exercise Prevention Program for Low Back Pain

OBJECTIVES

To identify relevant changes in process variables that are associated with outcome following an exercise and a multidisciplinary secondary prevention program for low back pain.

METHODS

Data from a randomized controlled clinical trial to examine the effectiveness of an exercise and a multidisciplinary prevention program were analyzed using multiple regression analyses. The specific goal was to examine the amount of variance in changes in "interference" postintervention that could be explained by prechanges to postchanges in physical and psychologic parameters, and to determine if there are interactions between physical/psychologic parameters and the program type.

RESULTS

One hundred sixty-two (89%) participants were included in the regression analyses. Reductions of interference at postmeasurement were explained best by reductions of pain intensity and catastrophizing in the multidisciplinary and the exercise prevention program. No significant interaction between the changes in process variables and the program type was found. The final model could explain 68.7% of variance.

CONCLUSIONS

Owing to methodologic limitations, strong conclusions cannot be drawn from this study. The findings suggest that treatment success in exercise and multidisciplinary interventions might be influenced by the same change factors, namely changes in pain and psychologic factors. The results raise the question of whether the mechanism through which exercise works, is improve in physical variables, or rather a change in psychologic attributes, in that people correct their irrational cognitions by making experiences that differ from their expectations. If these findings can be confirmed in longitudinal studies with more measurement points, they would have implications for treatment refinement.

Physical medicine rehabilitation approach to pain

A physical medicine and rehabilitation approach to acute and chronic pain syndromes includes a wide spectrum of treatment focus. Whether assessing or treating acute or chronic pain syndromes, management should include a biopsychosocial approach. Assessment may include a focused joint and functional examination including more global areas of impairment (ie, gait, balance, and endurance) and disability. More complicated multidimensional chronic pain conditions may require the use of a more collaborative continuum of multidisciplinary and interdisciplinary treatment approaches. Regardless of the scope of care that each individual patient requires, treatment options may include active physical therapy, rational polypharmacy, CBT, and the use of passive modalities. Treatment goals generally emphasize achieving analgesia, improving psychosocial functioning, and reintegration of recreational or leisure pursuits (ie, community activities and sports). Progress in all therapies necessitates close monitoring by the health care provider and necessitates ongoing communication between members of the treatment team. Although this article focuses on diagnoses related to acute and chronic low back pain, OA, and musculoskeletal disorders, assessment and treatment recommendations may be generalized to most other pain conditions.

Fear of movement/(re)injury in chronic pain: a psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK)

The Tampa scale for kinesiophobia (TSK) was developed to measure fear of movement/(re)injury in chronic pain patients. Although studies of the Dutch adaptation of the TSK have identified fear of movement/(re)injury as an important predictor of chronic pain, pain-related avoidance behaviour, and disability, surprisingly little data on the psychometric properties of the original English version of the TSK are available. The present study examined the reliability, construct validity and factor structure of the TSK in a sample of chronic pain patients (n=200) presenting for an interdisciplinary functional restoration program. Consistent with prior evaluations of the Dutch version of the TSK, the present findings indicate that the English TSK possesses a high degree of internal consistency and is positively associated with related measures of fear-avoidance beliefs, pain catastrophizing, pain-related disability and general negative affect. The TSK was not related to individual differences in physical performance testing as assessed using standardised treadmill and lifting tasks. Confirmatory factor analyses suggest that the TSK is best characterized by a three-factor trait method model that includes all 17 of the original scale items and takes into account the distinction between positively and negatively keyed items. The results of the present study provide important details regarding the psychometric properties of the original English version of the TSK and suggest that it may be unnecessary to remove the negatively keyed items in an attempt to improve scale validity.

Long-term exercise adherence in the elderly with chronic low back pain

OBJECTIVE

Chronic back pain is common in the elderly population and can be treated with exercise. Long-term adherence to exercise recommendations has been documented in adults of <65 yrs of age but not for elderly adults. This study explored exercise behaviors of elderly adults with a history of chronic back pain before and 2 yrs after treatment in an exercise-oriented rehabilitation program.

DESIGN

This study utilized a case series design to survey 126 subjects >65 yrs old who underwent physical therapy during the year 2000 for complaints of chronic low back pain. Of these, 89 (70%) responded to the 2-yr questionnaire. Outcome measures included visual analog scale for pain, Oswestry disability questionnaires, back flexibility and strength, and a questionnaire exploring exercise behaviors. All subjects underwent a 6-wk physical therapy program that consisted of exercise coupled with advice to remain active.

RESULTS

Improvements in flexibility and strength occurred during treatment. Mean Oswestry disability scores (0-100 scale) improved from 32 to 20, and pain scores (0-10 scale) from 5.0 to 3.0 during treatment (P < 0.001) and were maintained at the 2-yr follow-up, regardless of exercise adherence. The percentage of patients who performed at least some exercise increased from 49% before treatment to 72% at the 2-yr follow-up. The changes in disability or pain observed during treatment did not influence exercise compliance. The most frequently stated reasons for nonadherence was that exercise did not help or aggravated pain (33%). For those who exercised regularly, 80% did so because of the health benefits from exercise.

CONCLUSIONS

The exercise behaviors of many elderly adults with chronic low back pain can increase after an exercise-oriented spine physical therapy program.

The physician as disability advisor for patients with musculoskeletal complaints

STUDY DESIGN

Literature review.

OBJECTIVES

To review the literature about the performance of physicians as mediators of temporary and permanent disability for patients with chronic musculoskeletal complaints. To assess specifically the nature and variance of recommendations from physicians, factors influencing physician performance, and efforts to influence physician behavior in this area.

SUMMARY OF BACKGROUND DATA

While caring for patients with musculoskeletal injuries, physicians are often asked to recommend appropriate levels of activity and work. These recommendations have significant consequences for patients' general health, employment, and financial well-being.

METHODS

Medical literature search.

RESULTS

Physician recommendations limiting activity and work after injury are highly variable, often reflecting their own pain attitudes and beliefs. Patients' desires strongly predict disability recommendations (i.e., physicians often acquiesce to patients' requests). Other influences include jurisdiction, employer, insurer, and medical system factors. The most successful efforts to influence physician recommendations have used mass communication to influence public attitudes, while reinforcing the current standard of practice for physicians.

CONCLUSIONS

Physician recommendations for work and activity have important health and financial implications. Systemic, multidimensional approaches are necessary to improve performance.

Attitudes and beliefs of Brazilian and Australian physiotherapy students towards chronic back pain: a cross-cultural comparison

BACKGROUND AND PURPOSE

The attitudes and beliefs of physiotherapists and students can potentially influence the outcome of treatment of low back pain. These attitudes and beliefs may be influenced by external factors, such as ethnicity. No study that compared the attitudes and beliefs of physiotherapy students from different cultural backgrounds, such as from Brazil or Australia, towards chronic low back pain was found. The purpose of the present study was therefore to compare the attitudes and beliefs of Brazilian physiotherapy students with those of Australian physiotherapy students and to published data from North American healthcare providers, and to investigate whether a history of chronic low back pain affects students' attitudes and beliefs.

METHOD

A survey study design was used. Data were collected from 153 Brazilian physiotherapy students and compared with existing data from Australian physiotherapy students who had never been exposed to a chronic low back pain teaching module. Students' attitudes and beliefs were assessed by use of the HC-PAIRS questionnaire. These data were also compared with published data from North American healthcare providers.

RESULTS

The Brazilian physiotherapy students had significantly higher scores on the HC-PAIRS questionnaire than the Australian students and the North American healthcare providers. A previous history of chronic low back pain did not affect students' attitudes and beliefs.

CONCLUSIONS

As demonstrated by higher HC-PAIR scores, the Brazilian physiotherapy students agree more strongly with the notion that low back pain justifies disability and activity limitation than do Australian physiotherapy students and North American healthcare providers. A history of chronic low back pain does not affect students' attitudes and beliefs.

The attitudes and beliefs of physiotherapy students to chronic back pain

OBJECTIVES

To describe the attitudes and beliefs of physiotherapy students to chronic low back pain (LBP) and to investigate whether these attitudes change following exposure to a teaching module on chronic back pain. Also, to investigate the effect of current or previous LBP on student attitudes and beliefs.

METHODS

Six hundred and eighteen third and fourth year undergraduate physiotherapy students completed the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), 305 of these completing a further scale following exposure to a specialized teaching module about chronic back pain. The scale contains 15 statements that attribute patients' impairment and disability to pain. The student marked on a Likert scale how strongly they agreed with each item, with possible scores varying from 15-105.

RESULTS

The mean HC-PAIRS scores for Year 3 physiotherapy students in 1998, 1999, and 2000 were 54.2 (SD = 8.7), 55 (SD = 9.4), and 50.9 (SD = 9.3) respectively. The mean HC-PAIRS score for Year 4 physiotherapy students in 1998 was 52 (SD = 8.9). There was no difference in HC-PAIRS scores between subjects with and without a history of LBP (HC-PAIRS score 50.5 vs. 50.0 P = 0.4). There was a significant difference between the before and after teaching scores for Year 3 students surveyed immediately following the teaching module (1998 Year 3 cohort, mean difference -6.6, 95% CI -8.6 to -4.5, 2000 Year 3 cohort, mean difference -7.7, 95% CI -10.9 to -4.6); however this result needs to be viewed with caution due to the number of students unable to be followed up.

DISCUSSION

These results suggest that the attitudes and beliefs of third year physiotherapy students not exposed to teaching are similar to those of community providers. There is no difference between students with and without a history of LBP.

The influence of intense exercise-based physical therapy program on back pain anticipated before and induced by physical activities

BACKGROUND CONTEXT

Pain anticipated before and induced by physical activities has been shown to influence the physical performance of patients with chronic back pain. Limited data exist as to the influence of treatment on this component of pain.

PURPOSE

This study attempted to determine if pain anticipated before and induced by physical activities was altered during an exercise-oriented physical therapy program for chronic back pain.

STUDY DESIGN/SETTING

Subjects were recruited from three physical therapy sites with similar spine rehabilitation programs that used intense exercise delivered in a group format. During the recruitment period, 70 subjects with chronic low back pain and disability agreed to participate and complied with recommended treatments. The primary outcome measures were anticipated and induced pain as assessed by visual analog scales (VAS) during six tests of back flexibility and strength. Additional outcome measures included the performance levels of these six tests (trunk flexion, extension, straight leg raising, back strength, lifting from floor to waist and waist to shoulder height), global back and leg VAS and Oswestry Low Back Pain Disability Questionnaire scores.

METHODS

At evaluation for the spine rehabilitation programs, we recorded the anticipated and induced pain levels associated with the six tests of back function, the performance levels on each test and global pain and disability scores. Subjects then participated in the spine rehabilitation program that consisted of intense exercise delivered up to three times per week, for 2 hours over a period of 6 weeks. All outcome measures were reassessed at discharge. Pre- and posttreatment outcome scores were statistically compared using paired sample t tests and chi-squared test. Spearman correlation coefficients were used to compare anticipated and induced pain results with global back and leg pain VAS scores, Oswestry scores and physical performance levels for each physical test.

RESULTS

Most measures of anticipated and induced pain improved between evaluation and discharge. Improvements were noted for global back pain (p<.001), leg pain (p=.001), disability (p<.001) and performance on each physical testing (p<.001) after treatment. Performances on all physical testing correlated with anticipated and induced pain for all tests at evaluation but only for measures of flexibility at discharge. Improvements in global pain and disability correlated with improvements in anticipated and induced pain with physical testing.

CONCLUSION

Anticipated and induced pain with physical activities was lessened after physical therapy using exercise. Anticipated and induced pain with physical activities related to physical performance levels, global pain and disability ratings. These findings may help explain how exercise exerts a positive influence on chronic back pain and disability.

Exercise as a treatment for chronic low back pain

BACKGROUND CONTEXT

Exercise is a widely prescribed treatment for chronic low back pain, with demonstrated effectiveness for improving function and work.

PURPOSE

The goal of this article is to review several key aspects about the safety and efficacy of exercise that may help clinicians understand its utility in treating chronic back pain.

STUDY DESIGN/SETTING

A computerized literature search of MEDLINE was conducted using "exercise," "fitness," "back pain," "backache" and "rehabilitation" as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Additional references were acquired through the personal collections of research papers possessed by the authors and by reviewing prior review articles on this subject. These final papers were scrutinized for data relevant to the key aspects about exercise covered in this article.

RESULTS

For people with acute, subacute or chronic low back pain, there is no evidence that exercise increases the risk of additional back problems or work disability. To the contrary, current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of future back injuries. Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve or eliminate impairments in back flexibility and strength, and improve performance of endurance activities. There is a large body of evidence confirming that this goal can be accomplished for a majority of patients with chronic low back pain. The second goal of exercise is to reduce the intensity of back pain. Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10% to 50% after exercise treatment. The third goal of exercise is to reduce back pain-related disability through a process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect. The mechanisms through which exercise can accomplish this goal have been the subject of substantial research.

CONCLUSIONS

Exercise is safe for individuals with back pain, because it does not increase the risk of future back injuries or work absence. Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength. Most studies have observed improvements in global pain ratings after exercise programs, and many have observed that exercise can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes.

Pain beliefs and perceived physical disability of patients with chronic low back pain

Cognitive-behavioural therapy and maintenance of exercise have emerged as major tools in the treatment of patients with chronic low back pain. Patients' beliefs about their problem may influence their uptake of and responses to particular treatment modalities. In particular, we hypothesised that patients' beliefs about the cause and treatment of pain may mediate changes in physical disability following participation in a multidisciplinary pain management programme. A cohort of 84 patients was invited to respond to booklets of self-report questionnaires prior to, immediately after and 3 months following participation in multidisciplinary pain management programmes. Questionnaires addressed subjects' beliefs about the nature and treatment of pain (Pain Beliefs Questionnaire), and their disability (Likert-modified Roland and Morris Disability Questionnaire, Physical Functioning scale of the Short Form-36 Health Survey, and Oswestry Low Back Pain Disability Questionnaire). Patients with chronic low back pain who more strongly endorsed 'organic' concepts about the nature and treatment of pain reported higher levels of physical disability at baseline, and displayed greater reductions in disability following participation in the pain management programmes. Reductions in reported 'organic' pain beliefs were associated with improvements in reported disability. Endorsement of 'psychological' concepts about the nature and treatment of pain was not associated with disability. These findings support a view that patients' beliefs about the nature and treatment of their pain can change during participation in a multidisciplinary pain management programme based on cognitive-behavioural intervention. Modification of these beliefs may be associated with improvements in patients' perceptions of the level of their disability.

Aggressive exercise as treatment for chronic low back pain

Exercise has long been a standard of treatment for back pain. Over the last 2 decades, the use of intense, non-pain-contingent exercises for treatment of chronic back pain has received increased advocacy. The main goals of these treatments are to improve functioning of painful lumbar soft tissue and to decrease the fears and concerns of patients about using their backs for daily activities. The methodology of an aggressive quota-based exercise approach to back pain is outlined in this article. This approach relies on objective quantification of physical capabilities, treatment directed at altering these parameters, and repeat quantification for determination of treatment efficacy and positive feedback. By eliminating impairments in back function, altering fears and beliefs about pain, and reducing disability, patients with chronic low back pain can achieve meaningful improvements in their quality of life.

Quantifying social consequences of occupational injuries and illnesses: state of the art and research agenda

BACKGROUND

Quantitative methods for describing the social effects of occupational injury and illness are evaluated including surveys of prevalence and ratings of severity of social role disability.

METHODS

The reliability and validity for the injured worker population of the most commonly used general and condition-specific role disability measures is reviewed and summarized. This review is used to support the development of a prototype strategy for quantifying the social consequences of occupational injuries and to identify areas of need for further research and development.

CONCLUSIONS

Research is needed to: (a) determine which of existing measures is most precise in describing the severity of dysfunction due to a specific illness or injury, (b) expand the development of measures of specific role functioning (including paid work), and (c) develop item banks to support the construction of computer adaptive assessments of role functioning.

Impact of Huntington's disease on quality of life

The purpose of this study was to systematically assess the impact of Huntington's disease (HD) on patients' health-related quality of life (QOL). Seventy-seven patients with a clinically confirmed diagnosis of HD were interviewed by means of the Sickness Impact Profile (SIP). Additional data were gathered on patients' motor performance by means of the motor section of the Unified Huntington Disease Rating Scale (UHDRS), and cognitive performance by means of the Mini-Mental State (MMS). Patients had high scores on the SIP subscales, indicating moderate to severe functional impairment. Total Motor Score (TMS), MMS scores, and the duration of HD were significantly correlated with patients' scores on the SIP, and predicted a significant amount of variance of the Physical Dimension of the SIP, but not of the Psychosocial Dimension. We conclude that HD has a great impact on patients' physical and psychosocial well-being, the latter being more severely affected. Implications for further research and clinical practice are discussed.

Multidisciplinary treatment of chronic pain patients: its efficacy in changing patient locus of control

OBJECTIVE

To assess the efficacy of multidisciplinary treatment in altering chronic pain patient locus of control beliefs.

DESIGN

A before-and-after treatment design including demographics.

PARTICIPANTS

Seventy-three chronic nonmalignant pain patients who completed study questionnaires both before and after treatment.

SETTING

Comprehensive, outpatient, multidisciplinary pain management program at a large Midwestern university medical center.

MAIN OUTCOME MEASURES

Pain Locus of Control Scale and Survey of Pain Attitudes Control subscale.

RESULTS

Patients' perceptions of personal control over pain increased from pretreatment to posttreatment, and patients' perceptions of external control over pain, such as fate or powerful others. decreased from pretreatment to posttreatment.

CONCLUSIONS

This study supports the efficacy of chronic pain management centers in altering patient beliefs about pain. The ability to increase patients' self-efficacy in their control over pain and to decrease external attributions are essential to successful pain management.

Long-term exercise adherence after intensive rehabilitation for chronic low back pain

PURPOSE

The purpose of this study was to examine exercise compliance in patients with chronic low back pain (CLBP) after participation in an intensive spine rehabilitation program.

METHODS

Exercise behaviors in 122 consecutive subjects with CLBP who completed a program of quota based exercise were examined. Frequency per week of performance of four exercise activities, Oswestry disability scores, and visual analog scale (VAS) scores were assessed at evaluation, 3-month, and 12-month follow-up by patient-completed questionnaires.

RESULTS

Percentage of patients responding to initial, 3-month, and 12-month questionnaires were 100%, 86%, and 71%, respectively. Frequencies of exercise behaviors were compared by Wilcoxon signed-rank test and were found to increase significantly between evaluation and 3 months (P < 0.000), and evaluation and 12-month follow-up (P < 0.000). The percentages of patients reporting three or more times weekly performance of the following activities at evaluation and at three month follow-up, respectively, were: 1) stretching for the back and legs, 35% and 93%; 2) aerobic exercise, 44% and 87%; 3) back-strengthening exercises, 15% and 82%; and, 4) weight training, 6% and 71%. Evaluation and follow-up Oswestry disability and visual analog scale (VAS) scores for back pain were compared using Student's t-test. Significant improvements (P < 0.000) were noted for each of these scales at 3-month follow-up that were maintained at 12-month follow-up.

CONCLUSION

It is concluded that exercise behaviors can be increased and maintained in CLBP patients without adversely affecting pain or function.

Predictive validity of the pain and impairment relationship scale in a chronic nonmalignant pain population

OBJECTIVE

To examine the predictive and incremental validity of the Pain and Impairment Relationship Scale (PAIRS) and to determine its ability to measure changes in pain beliefs following interdisciplinary treatment.

DESIGN

A before-after treatment design.

SETTING

A comprehensive interdisciplinary pain center at a large midwest university medical center.

INTERVENTIONS

A cognitive-behavioral approach to pain management. The day-long program lasted 5 days a week for 4 weeks. Interventions were designed to improve physical functioning, reduce use of health care, and improve pain coping.

MAIN OUTCOME MEASURES

Six-month follow-up outcome measures included interference with daily activity, pain severity, and life control as measured by the Multidimensional Pain Inventory, medication use measured by the Medication Quantification Scale, depression measured by the Beck Depression Inventory, and the number of health care visits and pain-related hospitalizations.

RESULTS

Pretreatment PAIRS scores correlated significantly with interference with daily activities, pain severity, life control, health care visits, and depression. Stronger correlations were obtained between posttreatment PAIRS scores and all follow-up outcome measures. Posttreatment PAIRS scores accounted for a significant portion of the variance beyond that in demographic variables and pretreatment PAIRS scores in all but one of the follow-up measures. PAIRS scores changed significantly (p < .0001 ) in a positive direction after treatment.

CONCLUSIONS

The PAIRS has excellent predictive validity, and can be used effectively to monitor individual and programmatic changes.

Illness perceptions, coping and functioning in patients with rheumatoid arthritis, chronic obstructive pulmonary disease and psoriasis

The present cross-sectional study analyzed the extent to which illness perceptions and coping strategies (as measured by the Illness Perception Questionnaire and the Utrecht Coping List, respectively) are associated with levels of daily functioning, as indicated by the Medical Outcomes Study SF-20, and disease-specific measures in 244 adults: 84 with rheumatoid arthritis (RA); 80 with chronic obstructive lung disease (COPD); and 80 with psoriasis. The results of stepwise regression analyses indicated that a strong illness identity, passive coping, belief in a long illness duration, belief in more severe consequences, and an unfavorable score on medical variables were associated with worse outcome on disease-specific measures of functioning and on general role and social functioning. Coping by seeking social support and beliefs in controllability/curability of the disease were significantly related to better functioning. The implications of these findings for future interventions and research are discussed.

The effect of compensation involvement on the reporting of pain and disability by patients referred for rehabilitation of chronic low back pain

STUDY DESIGN

In this prospective, observational, cohort study of 192 individuals with chronic low back pain, the group of individuals was divided based on compensation involvement, and their presentation pain and disability, treatment recommendations, and compliance were compared. For 85 of these individuals who completed a spine rehabilitation program, their pain and disability at 3 and 12 months were compared.

OBJECTIVES

To test the theory that individuals with compensation involvement presented with greater pain and disability and would report less change of pain and disability after rehabilitation efforts.

BACKGROUND

Previous studies have produced conflicting results concerning this issue.

METHODS

Individuals were recruited as consecutive patients referred for consultation at a spine rehabilitation center. Pain, depression, and disability were assessed using self-report questionnaires at evaluation and at 3 and 12 months. Rehabilitation services consisted of aggressive, quota-based exercises aimed at correcting impairments in flexibility, strength, endurance, and lifting capacity, identified through quantification of back function. Multifactoral analysis of variance models were used to control for baseline differences between compensation and noncompensation patients during analysis of target variables.

RESULTS

The compensation group included 96 patients; these patients reported more pain, depression, and disability than the 96 patients without compensation involvement. These differences persisted when baseline differences were controlled for with multifactoral analysis of variance models. Treatment recommendations and compliance were not affected by compensation. For patients completing the spine rehabilitation program, length of treatment, flexibility, strength, lifting ability, and lower extremity work performance before and after treatment and patient satisfaction ratings were similar for the compensation and noncompensation groups. At 3 and 12 months, improvements in depression and disability were noted for both groups, but were statistically and clinically less substantial for the compensation group. At the 12 month follow-up visit, pain scores improved for the noncompensation group, but not for the compensation group.

CONCLUSIONS

In chronic low back pain, compensation involvement may have an adverse effect on self-reported pain, depression, and disability before and after rehabilitation interventions.