Chronic low back pain rehabilitation programs: a study of the optimum duration of treatment and a comparison of group and individual therapy

Identifying prognostic factors to determine the level of recovery in servicemembers with chronic low back pain: A prospective cohort study

OBJECTIVE

The main objective of this study was to identify general and military-related factors that are associated with the level of recovery in Dutch service members with chronic low back pain (CLBP) who followed a rehabilitation program.

MATERIAL AND METHOD

One hundred five consecutive service members with CLBP were included in this study. The level of disability, was used to distinguish a recovered and non-recovered group. Level of pain and self-perceived recovery were used as secondary outcome measurements. Differences were evaluated within and between the groups using the Student's t-test Bivariate logistic regression analyses were used for identifying the prognostic factors related to various outcomes of recoveryRESULTS: After following the rehabilitation program, 64.8% of the service members recovered from CLBP. The recovered group, demonstrated significant effect sizes in disability and in pain The non-recovered group showed on disability a non-significant effect and in pain a significant effect. The self-perceived recovery in the recovered group was "much improved" and the non-recovered group "slightly improved". The results of the bivariate regression analyses showed no significant independent prognostic factors related to recovery.

CONCLUSIONS

In this study, no significant independent prognostic factors could be identified that were associated to the various outcomes of recovery in service members with CLBP who followed a rehabilitation program.

Improvement in pain interference and function by an allied health pain management program: Results of a randomized trial

BACKGROUND

Chronic pain is a significant health problem worldwide and requires a biopsychosocial treatment approach. Access to traditional pain medicine specialist services is limited and innovative treatment models are required to support patients in tertiary care. The study evaluated the clinical effectiveness and safety of the Treatment Access Pathway (TAP), an allied health expanded scope model of care which included innovative group assessment and collaboration with patients to create individualized treatment plans.

METHODS

One hundred and eighty-one patients referred to a tertiary level chronic pain service were randomly allocated to either the TAP or the waitlist study groups. Primary (pain interference) and secondary outcome measures were collected at recruitment and again at 6 months. Per-protocol analyses were utilized due to high participant attrition (46% across groups).

RESULTS

The TAP group reported greater reductions in pain interference at 6 months than waitlist group (0.9, 95% CI: 0.2-1.6), with more than half of the TAP group (52%) reporting clinically significant improvement. In addition, statistically significant differences between the TAP and waitlist groups were observed for objective measurements of walking endurance (5.4 m, 95% CI: 1.7-9.1); and global impressions of change (1.4 unit decrease, 95% CI: 1-1.9). Nil adverse events were recorded.

CONCLUSIONS

The study suggests that an expanded scope allied health model of care prioritizing patient choice and group-based interventions provides modest benefits for tertiary-referral chronic pain patients. TAP warrants further investigation as a potentially viable alternative for tertiary healthcare where traditional pain services are unavailable or have long waiting lists.

SIGNIFICANCE

The study tests effectiveness and safety of an expanded scope allied health-led chronic pain program. Despite a high attrition rate, the study showed reduced pain interference and increased physical function in those who completed the protocol. The results are promising and support introduction of this model as an adjunct to existing traditional chronic pain models of care, with a particular focus on improving participant retention in the program. Additionally, the model of care can be used as a standalone chronic pain model of care where no other pain management resources are available. The study was registered on ANZCTR (Trial ID: ACTRN12617001284358).

Effectiveness of psychological interventions to improve quality of life in people with long-term conditions: rapid systematic review of randomised controlled trials

Background

Long-term conditions may negatively impact multiple aspects of quality of life including physical functioning and mental wellbeing. The rapid systematic review aimed to examine the effectiveness of psychological interventions to improve quality of life in people with long-term conditions to inform future healthcare provision and research.

Methods

EBSCOhost and OVID were used to search four databases (PsychInfo, PBSC, Medline and Embase). Relevant papers were systematically extracted by one researcher using the predefined inclusion/exclusion criteria based on titles, abstracts, and full texts. Randomized controlled trial psychological interventions conducted between 2006 and February 2016 to directly target and assess people with long-term conditions in order to improve quality of life were included. Interventions without long-term condition populations, psychological intervention and/or patient-assessed quality of life were excluded.

Results

From 2223 citations identified, 6 satisfied the inclusion/exclusion criteria. All 6 studies significantly improved at least one quality of life outcome immediately post-intervention. Significant quality of life improvements were maintained at 12-months follow-up in one out of two studies for each of the short- (0–3 months), medium- (3–12 months), and long-term (≥ 12 months) study duration categories.

Conclusions

All 6 psychological intervention studies significantly improved at least one quality of life outcome immediately post-intervention, with three out of six studies maintaining effects up to 12-months post-intervention. Future studies should seek to assess the efficacy of tailored psychological interventions using different formats, durations and facilitators to supplement healthcare provision and practice.

Assessment of Adults Experiencing Chronic Non-Cancer Pain: A Randomized Trial of Group Versus Individual Format at an Australian Tertiary Pain Service

OBJECTIVE

To compare the outcomes of a new group assessment format with conventional individual assessment.

DESIGN

A randomized controlled trial.

SETTING

An Australian tertiary hospital multidisciplinary pain service.

PATIENTS

Adults referred with chronic non-cancer pain.

METHODS

Following attendance at an education and orientation group, 211 participants were randomized to either a group assessment format (focused on supported self-assessment) or individual assessment. Follow-up occurred 3 months post-assessment and prior to subsequent pain service intervention. Outcome measures were pain intensity, pain interference, self-efficacy, psychological distress, health care utilization beyond the pain service, waiting time, participant satisfaction, and implementation of self-management strategies.

RESULTS

Seventy-two participants undertook group assessment and 90 were assessed individually. Follow-up data were collected on 57 group and 72 individual assessment participants. Results revealed no significant differences between the two assessment formats in outcome with the exception of wait-times. Median wait-time to the first offer of assessment was 47 days for the group format and 144 days for individual.

CONCLUSIONS

Group assessment provides a viable alternative to conventional individual assessment. The group assessment reduced wait-times while delivering otherwise comparable outcomes.

Reporting of Sex Effects by Systematic Reviews on Interventions for Depression, Diabetes, and Chronic Pain

Systematic reviews (SRs) have the potential to contribute uniquely to the evaluation of sex and gender differences (termed "sex effects"). This article describes the reporting of sex effects by SRs on interventions for depression, type 2 diabetes mellitus, and chronic pain conditions (chronic low back pain, knee osteoarthritis, and fibromyalgia). It includes SRs published since 1 October 2009 that evaluate medications, behavioral interventions, exercise, quality improvement, and some condition-specific treatments. The reporting of sex effects by primary randomized, controlled trials is also examined. Of 313 eligible SRs (86 for depression, 159 for type 2 diabetes mellitus, and 68 for chronic pain), few (n = 29) reported sex effects. Most SRs reporting sex effects used metaregression, whereas 9 SRs used subgroup analysis or individual-patient data meta-analysis. The proportion of SRs reporting the sex distribution of primary studies varied from a low of 31% (n = 8) for low back pain to a high of 68% (n = 23) for fibromyalgia. Primary randomized, controlled trials also infrequently reported sex effects, and most lacked an adequate sample size to examine them. Therefore, all SRs should report the proportion of women enrolled in primary studies and evaluate sex effects using appropriate methods whenever power is adequate.

Getting "Unstuck": A Multi-Site Evaluation of the Efficacy of an Interdisciplinary Pain Intervention Program for Chronic Low Back Pain

Chronic low back pain is one of the major health problems in the U.S., resulting in a large number of years of disability. To address the biopsychosocial nature of pain, interdisciplinary pain programs provide integrated interventions by an interdisciplinary team in a unified setting with unified goals. This study examined outcomes of an interdisciplinary program located at two sites with different staff, yet with a unified model of treatment and documentation. Efficacy at the combined sites was examined by comparing standard measures obtained upon admission to the program with measures at completion of a 3-4 week long program for 393 patients with chronic low back pain (CLBP). Repeated measures included pain severity, pain interference, efficacy of self-management strategies, hours of activity, depression, ability to do ADLs, and physical endurance. All repeated measures differed at the p < 0.001 level, with large effect sizes (0.66-0.85). Eighty-two percent of graduates reported being "very much improved" or "much improved". A second analyses provided evidence that treatment effects were robust across sites with no differences (<0.001) found on five of seven selected outcome measures. A third analysis found that number of days of treatment was correlated on three of seven measures at the <0.01 level. However, the amount of variance explained by days of treatment was under 5% on even the most highly correlated measure. These finding are consistent with previous research and explore short-term effectiveness of treatment across treatment sites and with variable duration of treatment.

Psychological Treatments and Psychotherapies in the Neurorehabilitation of Pain: Evidences and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

BACKGROUND

It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams.

OBJECTIVES

To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases.

METHODS

A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions.

RESULTS

The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive-Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post-Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache.

CONCLUSIONS

Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the paper.

Outpatient Combined Group and Individual Cognitive-Behavioral Treatment for Patients With Migraine and Tension-Type Headache in a Routine Clinical Setting

OBJECTIVE

To test the long-term clinical effectiveness (follow-up at 3, 6 and 12 months) of an outpatient combined group and individual cognitive-behavioral treatment (CBT) for headache patients following standard medical care. A decrease in headache intensity, frequency, headache-specific impairment, depression, and change of pain-related cognitions was expected.

BACKGROUND

The efficacy of CBT for primary headaches has been confirmed in research, yet the translation into clinical practice has remained untested thus far.

DESIGN

In this single-group outcome study, 87 headache patients diagnosed with migraine and/or tension-type headache received (1) headache-specific medication for 10 weeks and (2) a subsequent CBT treatment made up of 13 individual and 12 group sessions consisting of psychoeducation, progressive muscle relaxation, coping strategies for pain and stress, and goal setting skills. Booster group sessions after 3 and 6 months were implemented to stimulate individual goal attainment, and follow-up measures were recorded up to 12 months.

RESULTS

A significant decrease was found for all primary and secondary outcome criteria, ie, average headache intensity (prae M: 6.0, standard deviation [SD]: 1.5 vs follow-up [FU] 1 year M: 5.1, SD: 1.9), headache frequency (prae M: 16.0, SD: 9.5 vs FU 1 year M: 13.4, SD: 9.9), and catastrophizing (prae M: 3.4, SD: 1.0 vs FU 1 year M: 2.6, SD: 1.1). Coping strategies were increased (prae M: 3.4, SD: .9 vs FU 1 year M: 4.0, SD: 1.0).

CONCLUSION

CBT treatment is a useful component within a routine clinical setting and can improve standard medical care thereby helping patients in managing their headache pain.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain

BACKGROUND

Low back pain (LBP) is responsible for considerable personal suffering worldwide. Those with persistent disabling symptoms also contribute to substantial costs to society via healthcare expenditure and reduced work productivity. While there are many treatment options, none are universally endorsed. The idea that chronic LBP is a condition best understood with reference to an interaction of physical, psychological and social influences, the 'biopsychosocial model', has received increasing acceptance. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds.

OBJECTIVES

To review the evidence on the effectiveness of MBR for patients with chronic LBP. The focus was on comparisons with usual care and with physical treatments measuring outcomes of pain, disability and work status, particularly in the long term.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL databases in January and March 2014 together with carrying out handsearches of the reference lists of included and related studies, forward citation tracking of included studies and screening of studies excluded in the previous version of this review.

SELECTION CRITERIA

All studies identified in the searches were screened independently by two review authors; disagreements regarding inclusion were resolved by consensus. The inclusion criteria were published randomised controlled trials (RCTs) that included adults with non-specific LBP of longer than 12 weeks duration; the index intervention targeted at least two of physical, psychological and social or work-related factors; and the index intervention was delivered by clinicians from at least two different professional backgrounds.

DATA COLLECTION AND ANALYSIS

Two review authors extracted and checked information to describe the included studies, assessed risk of bias and performed the analyses. We used the Cochrane risk of bias tool to describe the methodological quality. The primary outcomes were pain, disability and work status, divided into the short, medium and long term. Secondary outcomes were psychological functioning (for example depression, anxiety, catastrophising), healthcare service utilisation, quality of life and adverse events. We categorised the control interventions as usual care, physical treatment, surgery, or wait list for surgery in separate meta-analyses. The first two comparisons formed our primary focus. We performed meta-analyses using random-effects models and assessed the quality of evidence using the GRADE method. We performed sensitivity analyses to assess the influence of the methodological quality, and subgroup analyses to investigate the influence of baseline symptom severity and intervention intensity.

MAIN RESULTS

From 6168 studies identified in the searches, 41 RCTs with a total of 6858 participants were included. Methodological quality ratings ranged from 1 to 9 out 12, and 13 of the 41 included studies were assessed as low risk of bias. Pooled estimates from 16 RCTs provided moderate to low quality evidence that MBR is more effective than usual care in reducing pain and disability, with standardised mean differences (SMDs) in the long term of 0.21 (95% CI 0.04 to 0.37) and 0.23 (95% CI 0.06 to 0.4) respectively. The range across all time points equated to approximately 0.5 to 1.4 units on a 0 to 10 numerical rating scale for pain and 1.4 to 2.5 points on the Roland Morris disability scale (0 to 24). There was moderate to low quality evidence of no difference on work outcomes (odds ratio (OR) at long term 1.04, 95% CI 0.73 to 1.47). Pooled estimates from 19 RCTs provided moderate to low quality evidence that MBR was more effective than physical treatment for pain and disability with SMDs in the long term of 0.51 (95% CI -0.01 to 1.04) and 0.68 (95% CI 0.16 to 1.19) respectively. Across all time points this translated to approximately 0.6 to 1.2 units on the pain scale and 1.2 to 4.0 points on the Roland Morris scale. There was moderate to low quality evidence of an effect on work outcomes (OR at long term 1.87, 95% CI 1.39 to 2.53). There was insufficient evidence to assess whether MBR interventions were associated with more adverse events than usual care or physical interventions.Sensitivity analyses did not suggest that the pooled estimates were unduly influenced by the results from low quality studies. Subgroup analyses were inconclusive regarding the influence of baseline symptom severity and intervention intensity.

AUTHORS' CONCLUSIONS

Patients with chronic LBP receiving MBR are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status compared to physical treatment. Effects are of a modest magnitude and should be balanced against the time and resource requirements of MBR programs. More intensive interventions were not responsible for effects that were substantially different to those of less intensive interventions. While we were not able to determine if symptom intensity at presentation influenced the likelihood of success, it seems appropriate that only those people with indicators of significant psychosocial impact are referred to MBR.

Description and design considerations of a randomized clinical trial investigating the effect of a multidisciplinary cognitive-behavioural intervention for patients undergoing lumbar spinal fusion surgery

Background

The ideal rehabilitation strategy following lumbar spinal fusion surgery has not yet been established. This paper is a study protocol, describing the rationale behind and the details of a cognitive-behavioural rehabilitation intervention for lumbar spinal fusion patients based on the best available evidence. Predictors of poor outcome following spine surgery have been identified to provide targets for the intervention, and the components of the intervention were structured in accordance with the cognitive-behavioural model. The study aims to compare the clinical and economical effectiveness of a cognitive-behavioural rehabilitation strategy to that of usual care for patients undergoing lumbar spinal fusion surgery.

Methods/Design

The study is a randomized clinical trial including 96 patients scheduled for lumbar spinal fusion surgery due to degenerative disease or spondylolisthesis. Patients were recruited in the period October 2011 to July 2013, and the follow-up period is one year from date of surgery. Patients are allocated on a 1:2 ratio (control: intervention) to either treatment as usual (control group), which implies surgery and the standard postoperative rehabilitation, or in addition to this, a patient education focusing on pain behaviour and pain coping (intervention group). It takes place in a hospital setting, and consists of six group-based sessions, managed by a multidisciplinary team of health professionals.

The primary outcomes are disability (Oswestry Disability Index) and sick leave, while secondary outcomes include coping (Coping Strategies Questionnaire), fear-avoidance belief (Fear Avoidance Belief Questionnaire), pain (Low Back Pain Rating Scale, pain index), mobility during hospitalization (Cumulated Ambulation Score), generic health-related quality of life (EQ-5D) and resource use. Outcomes are measured using self report questionnaires, medical records and national registers.

Discussion

It is expected that the intervention can provide better functional outcome, less pain and earlier return to work after lumbar spinal fusion surgery. By combining knowledge and evidence from different knowledge areas, the project aims to provide new knowledge that can create greater consistency in patient treatment. We expect that the results can make a significant contribution to development of guidelines for good rehabilitation of patients undergoing lumbar spinal fusion.

Trial registration

Current Controlled Trials ISRCTN42281022.

Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain

Purpose

The aim of this study is to provide a narrative review of the current state of knowledge of the role of cognitive behavioral therapy (CBT) in the management of chronic nonspecific back pain.

Methods

A literature search on all studies published up until July 2012 (PubMed and PsycINFO) was performed. The search string consisted of 4 steps: cognitive behavioral therapy/treatment/management/modification/intervention, chronic, back pain (MeSH term) or low back pain (MeSH term), and randomized controlled trial (MeSH term). The conclusions are based on the results from randomized controlled trials (RCTs) and reviews of RCTs. Interventions were not required to be pure CBT interventions, but were required to include both cognitive and behavioral components.

Results

The search yielded 108 studies, with 46 included in the analysis. Eligible intervention studies were categorized as CBT compared to wait-list controls/treatment as usual, physical treatments/exercise, information/education, biofeedback, operant behavioral treatment, lumbar spinal fusion surgery, and relaxation training. The results showed that CBT is a beneficial treatment for chronic back pain on a wide range of relevant variables, especially when compared to wait-list controls/treatment as usual. With regards to the other comparison treatments, results were mixed and inconclusive.

Conclusion

The results of this review suggest that CBT is a beneficial treatment for chronic nonspecific back pain, leading to improvements in a wide range of relevant cognitive, behavioral and physical variables. This is especially evident when CBT is compared to treatment as usual or wait-list controls, but mixed and inconclusive when compared with various other treatments. Multidisciplinary and transdisciplinary interventions that integrate CBT with other approaches may represent the future direction of management of chronic back pain, with treatments modified for specific circumstances and stakeholders. There is a need for future intervention studies to be specific in their use of cognitive behavioral elements, in order for results to be comparable.

A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain

Low back pain (LBP) is a common and disabling disorder in western society. The management of LBP comprises a range of different intervention strategies including surgery, drug therapy, and non-medical interventions. The objective of the present study is to determine the effectiveness of physical and rehabilitation interventions (i.e. exercise therapy, back school, transcutaneous electrical nerve stimulation (TENS), low level laser therapy, education, massage, behavioural treatment, traction, multidisciplinary treatment, lumbar supports, and heat/cold therapy) for chronic LBP. The primary search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to 22 December 2008. Existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria. The search strategy outlined by the Cochrane Back Review Groups (CBRG) was followed. The following were included for selection criteria: (1) randomized controlled trials, (2) adult (≥ 18 years) population with chronic (≥ 12 weeks) non-specific LBP, and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery, or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias, and outcomes at short, intermediate, and long-term follow-up. The GRADE approach was used to determine the quality of evidence. In total 83 randomized controlled trials met the inclusion criteria: exercise therapy (n = 37), back school (n = 5), TENS (n = 6), low level laser therapy (n = 3), behavioural treatment (n = 21), patient education (n = 1), traction (n = 1), and multidisciplinary treatment (n = 6). Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. Behavioural treatment was found to be effective in reducing pain intensity at short-term follow-up compared to no treatment/waiting list controls. Finally, multidisciplinary treatment was found to reduce pain intensity and disability at short-term follow-up compared to no treatment/waiting list controls. Overall, the level of evidence was low. Evidence from randomized controlled trials demonstrates that there is low quality evidence for the effectiveness of exercise therapy compared to usual care, there is low evidence for the effectiveness of behavioural therapy compared to no treatment and there is moderate evidence for the effectiveness of a multidisciplinary treatment compared to no treatment and other active treatments at reducing pain at short-term in the treatment of chronic low back pain. Based on the heterogeneity of the populations, interventions, and comparison groups, we conclude that there are insufficient data to draw firm conclusion on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP.

Behavioural treatment for chronic low-back pain

BACKGROUND

Behavioural treatment is commonly used in the management of chronic low-back pain (CLBP) to reduce disability through modification of maladaptive pain behaviours and cognitive processes. Three behavioural approaches are generally distinguished: operant, cognitive, and respondent; but are often combined as a treatment package.

OBJECTIVES

To determine the effects of behavioural therapy for CLBP and the most effective behavioural approach.

SEARCH STRATEGY

The Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, and PsycINFO were searched up to February 2009. Reference lists and citations of identified trials and relevant systematic reviews were screened.

SELECTION CRITERIA

Randomised trials on behavioural treatments for non-specific CLBP were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach.

MAIN RESULTS

We included 30 randomised trials (3438 participants) in this review, up 11 from the previous version. Fourteen trials (47%) had low risk of bias. For most comparisons, there was only low or very low quality evidence to support the results. There was moderate quality evidence that:i) operant therapy was more effective than waiting list (SMD -0.43; 95%CI -0.75 to -0.11) for short-term pain relief;ii) little or no difference exists between operant, cognitive, or combined behavioural therapy for short- to intermediate-term pain relief;iii) behavioural treatment was more effective than usual care for short-term pain relief (MD -5.18; 95%CI -9.79 to -0.57), but there were no differences in the intermediate- to long-term, or on functional status;iv) there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate- to long-term;v) adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone.

AUTHORS' CONCLUSIONS

For patients with CLBP, there is moderate quality evidence that in the short-term, operant therapy is more effective than waiting list and behavioural therapy is more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.

Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review

BACKGROUND

Graded activity and graded exposure are increasingly being used in the management of persistent low back pain; however, their effectiveness remains poorly understood.

PURPOSE

The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain.

DATA SOURCES

Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10).

STUDY SELECTION

Randomized controlled trials of graded activity or graded exposure that included pain, disability, global perceived effect, or work status outcomes were included in the study.

DATA EXTRACTION

Outcomes were converted to a scale from 0 to 100. Trials were pooled with software used for preparing and maintaining Cochrane reviews.

RESULTS

are presented as weighted mean differences with 95% confidence intervals.

DATA SYNTHESIS

Fifteen trials with 1,654 patients were included. The trials had a median quality score of 6 (range=3-9). Pooled effects from 6 trials comparing graded activity with a minimal intervention or no treatment favored graded activity, with 4 contrasts being statistically significant: mean values (95% confidence intervals) for pain in the short term, pain in the intermediate term, disability in the short term, and disability in the intermediate term were -6.2 (-9.4 to -3.0), -5.5 (-9.9 to -1.0), -6.5 (-10.1 to -3.0), and -3.9 (-7.4 to -0.4), respectively. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant.

LIMITATIONS

Limitations of this review include the low quality of the studies, primarily those that evaluated graded exposure; the use of various types of outome measures; and differences in the implementation of the interventions, adding to the heterogeneity of the studies.

CONCLUSIONS

The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain. The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain.

The effects of a back rehabilitation programme for patients with chronic low back pain

AIM

The aim of this paper was to perform a pragmatic before-after analysis of a back rehabilitation programme (BRP) for patients with chronic low back pain (LBP). A total of 877 patients were recruited onto the BRP, which were carried out at four centres within the Wrightington, Wigan and Leigh NHS Trust. The BRP consisted of nine 2-hour group sessions of therapy run over 5 weeks and included 1 hour of exercise and 1 hour of education, advice problem solving and goal setting.

METHOD

Using the Wilcoxen signed rank tests and paired t-tests levels of pain, disability, anxiety and depression were significantly reduced pre-post programme (P < 0.001). In addition, the levels of fitness and perceived control improved significantly (P < 0.001) suggesting that participants were better able to manage their LBP.

CONCLUSION

Overall, the BRP proved to be effective in reducing pain, disability, anxiety and depression levels for people with chronic LBP. However, despite significant improvements in outcome measures only 50% of the patients completed the BRP and questionnaires post BRP. The implications of the findings are discussed with respect to modified programmes and alternative management for patients within different subgroups of LBP.

Patient education in physiotherapy of low back pain: acute outcomes of group instruction

BACKGROUND

Adults with recalcitrant mechanical low back pain of more than six weeks duration can encounter unacceptable waiting periods for specialised care.

AIM

To evaluate the effectiveness of rapid treatment by means of group sessions.

METHODS

We instituted a rapidly accessed patient education programme in physiotherapy for low back pain. Pain and disability were assessed before and after the programme. The programme included four sessions of group instruction for self-actuated physiotherapy There were six to 10 patients per group.

RESULTS

In eight months, 160 patients were admitted to the programme. The average waiting time was 16 business days for the first appointment. Seventy-three per cent of the patients who attended some portion of the programme completed all sessions. At least 30% of the incompletions were ascribable to rapid improvement. Of patients completing the programme, 80% reported significant resolution of the pain and improvement in function. Twenty per cent reported no significant response, but no patients worsened during participation. Of the 20% with no subjective improvement, 50% were pursuing medico-legal claims. In comparison, 9% of those reporting a successful response were pursuing litigation.

CONCLUSIONS

Group instruction in physiotherapy for low back pain is safe, generally successful, and highly acceptable to patients.

Behavioural treatment for chronic low-back pain

BACKGROUND

Behavioural treatment, commonly used in the treatment of chronic low-back pain (CLBP), is primarily focused at reducing disability through the modification of environmental contingencies and cognitive processes. In general, three behavioural treatment approaches are distinguished: operant, cognitive and respondent.

OBJECTIVES

To determine if behavioural therapy is more effective than reference treatments for CLBP, and which type of behavioural treatment is most effective.

SEARCH STRATEGY

We searched the CENTRAL, MEDLINE, EMBASE, and PsycLIT databases up to October 2003. References of identified randomised trials and relevant systematic reviews were screened.

SELECTION CRITERIA

Only randomised trials on behavioural treatment for non-specific CLBP were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the methodological quality and extracted the data. The magnitude of effect was assessed by computing a pooled effect size for post-treatment and long-term results for each comparison, for each domain (i.e., behavioural outcomes, overall improvement, back pain specific and generic functional status, return to work, and pain intensity) using the random effects model.

MAIN RESULTS

Seven studies (33%) were considered high quality. Comparing behavioural treatment to waiting list control (WLC) revealed strong evidence (4 trials, 134 people) in favour of a combined respondent-cognitive therapy for a medium positive effect on pain, and moderate evidence (2 trials, 39 people) in favour of progressive relaxation for a large positive effect on pain and behavioural outcomes (short-term only). When comparing operant treatment to WLC no significant differences could be detected on general functional status (strong evidence: 2 trials, 87 people) or on behavioural outcomes (moderate evidence; 3 trials, 153 people) (short-term only). There is limited evidence (1 trial, 98 people) that a graded activity program in an industrial setting is more effective than usual care for early return to work and reduced long-term sick leave. There is limited evidence (1 trail, 39 people) that there are no differences between behavioural treatment and exercises. Finally, there is moderate evidence (6 trials, 210 people) that there are no significant differences in short-term and long-term effectiveness when behavioural components are added to usual treatment programs for CLBP (i.e. physiotherapy, back education) on pain, generic functional status and behavioural outcomes.

AUTHORS' CONCLUSIONS

Combined respondent-cognitive therapy and progressive relaxation therapy are more effective than WLC on short-term pain relief. However, it is unknown whether these results sustain in the long term. No significant differences could be detected between behavioural treatment and exercise therapy. Whether clinicians should refer patients with CLBP to behavioural treatment programs or to active conservative treatment cannot be concluded from this review.

Patients' perspectives on self-management following a back rehabilitation programme

OBJECTIVE

The management of chronic low back pain (CLBP) is becoming increasingly demanding upon health care services and society. Programmes combining exercise, education and a biopsychosocial approach have become a popular way of managing CLBP. Programmes are designed to change behaviour, increase activity levels and encourage self-management. Patients' experiences of attending a back rehabilitation programme were examined.

METHODS

This study used a qualitative approach combining interviews, non-participant observation and evaluation of documentation to establish the patients' perspective of self-management following a back programme.

RESULTS

All the patients (n = 6 ) indicated they were self-managing by continuing to exercise and utilizing the advice given after attendance. Two patients felt they should continue attending the therapy department to exercise in order to gain benefit, demonstrating reliance on continued health care support. Obstacles to continuing with exercise were cited as pain, time, and family constraints. Patients also expressed limitations following attendance regarding the type and level of activity their CLBP would allow them to manage. The data suggested activity limitation was inadvertently reinforced by the therapists during the sessions, in the programme letter and by the patients' existing beliefs regarding the cause of their CLBP.

CONCLUSION

The study demonstrated the importance of understanding patients' beliefs and expectations prior to a back programme and accounting for these during attendance. This study also highlighted that all heath care professionals should be aware of the impact of the language and terminology used when working with CLBP patients.

Outpatient cognitive behavioral pain management programs: a randomized comparison of a group-based multidisciplinary versus an individual therapy model

OBJECTIVE

To compare the efficacy of 2 models of chronic pain management.

DESIGN

Randomized comparative trial with 2 active treatment arms.

SETTING

Outpatient pain management clinics.

PARTICIPANTS

A total of 113 adults with chronic pain of 0.5 to 38 years duration in (mean, 8.8y).

INTERVENTIONS

Cognitive behavioral therapy (including education, relaxation, use of cognitive coping strategies, pacing, exercise) delivered in group-based multidisciplinary program or in an individual therapy program.

MAIN OUTCOME MEASURES

Self-report of interference with daily activities and sense of control over pain (West Haven-Yale Multidimensional Pain Inventory [WHYMPI]) and depression (Beck Depression Inventory). Secondary outcome measures were state anxiety (Spielberger State-Trait Anxiety conventory), analgesic medication consumption, general activity, and pain severity (WHYMPI). Measurement points were 0 (before treatment), 2 months (end of treatment), and 3, 6 and 12 months (follow-up).

RESULTS

No significant differences were found between the 2 modes of treatment at any of the major time points (0, 2, 12mo). Both treatment conditions made significant and sustained improvements on all primary outcome measures, although sense of control over pain tended to decline by 1 year. Individually treated participants made slower gains in some areas, but showed a lesser tendency to rebound at the end of treatment.

CONCLUSION

The 2 programs appear to be equally efficacious for pain management in adults with chronic pain. In practical terms, the choice of model for service provision may rest more on local issues such as the availability of space and staff time.

Stress Management and Workplace Disability in the US, Europe and Japan

Although the health care costs and the number of disability cases across all medical illnesses have increased, disability management programs implementing stress management interventions have been found to improve physical and mental health, reduce costs to employers, and facilitate the reintegration of injured individuals into the work environment. Stress management programs limit the impact and chronicity of disabilities and can be used to reduce and control the cost of disability in the workplace. Providing the most efficacious behavioral interventions thereby allows employers, employees and health professionals to work cooperatively to achieve optimum health and cost effectiveness. This review presents a variety of group and individual interventions, which have been utilized to aid disabled employees in coping with work-related injuries and medical illness. The implementation of stress management interventions in the workplace is described in detail, with special emphasis on the use of cognitive behavioral stress management. Finally, this review outlines a team approach to the application of a workplace stress management intervention aimed at reducing the overall impact of disability.

Efficacy of rehabilitative therapy in regional musculoskeletal conditions

This chapter reviews the best evidence for the rehabilitation of regional musculoskeletal conditions. Evidence-based efficacy of different modalities for treatment of musculoskeletal pain is presented, and the value of the patient's active participation in the rehabilitation programme is emphasized. The following modalities are commonly included in the holistic approach to patient-centred care and are reviewed: exercise therapy, thermotherapy, transcutaneous electrical nerve stimulation (TENS), and alternative therapies such as acupuncture, massage and yoga. A review of cognitive-behavioural strategies in pain management to prevent or treat fear-avoidance behaviour is also presented. Furthermore, the application of biomechanics in treating and preventing musculoskeletal disorders is illustrated. Moreover, the evidence for pain self-management to improve symptoms, health status and decrease the utilization of health care resources and cost is outlined. Finally, an overview will be presented, concerning the application of the evidence for treatment modalities to patient care, with focus on patient-centred, holistic treatment in a supportive setting. The following key questions/issues are addressed. What are the relevant therapeutic modalities for musculoskeletal pain disorders? What is the evidence of efficacy of these modalities in regional musculoskeletal conditions? What is the importance of understanding biomechanics? What is the importance of understanding fear-avoidance beliefs? What is the evidence for 'alternative' therapies such as acupuncture, massage or yoga? What is the evidence for 'pain self-management?' How does one apply the evidence for rehabilitation in regional musculoskeletal conditions into clinical practice?

Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care?

OBJECTIVES

To determine the strength of evidence for the effectiveness of mental health interventions for patients with three common somatic conditions (chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain). To assess whether results obtained in secondary care can be extrapolated to primary care and suggest how future trials should be designed to provide more rigorous evidence.

DESIGN

Systematic review.

DATA SOURCES

Five electronic databases, key texts, references in the articles identified, and citations from expert clinicians.

STUDY SELECTION

Randomised controlled trials including participants with one of the three conditions for which no physical cause could be found. Two reviewers screened sources and independently extracted data and assessed quality.

RESULTS

Sixty one studies were identified; 20 were classified as primary care and 41 as secondary care. For some interventions, such as brief psychodynamic interpersonal therapy, little research was identified. However, results of meta-analyses and of randomised controlled trials suggest that cognitive behaviour therapy and behaviour therapy are effective for chronic back pain and chronic fatigue syndrome and that antidepressants are effective for irritable bowel syndrome. Cognitive behaviour therapy and behaviour therapy were effective in both primary and secondary care in patients with back pain, although the evidence is more consistent and the effect size larger for secondary care. Antidepressants seem effective in irritable bowel syndrome in both settings but ineffective in chronic fatigue syndrome.

CONCLUSIONS

Treatment seems to be more effective in patients in secondary care than in primary care. This may be because secondary care patients have more severe disease, they receive a different treatment regimen, or the intervention is more closely supervised. However, conclusions of effectiveness should be considered in the light of the methodological weaknesses of the studies. Large pragmatic trials are needed of interventions delivered in primary care by appropriately trained primary care staff.

Scaling of the revised Oswestry low back pain questionnaire

OBJECTIVE

To evaluate the measurement properties of the Revised Oswestry Disability Questionnaire (RODQ) by using rating scale analyses.

DESIGN

Calibration of item responses by using a data set.

SETTING

Four outpatient therapy clinics in the northeastern United States.

PATIENTS

Convenience sample of 95 community-dwelling adults exhibiting mild to severe low back pain-related disability (LBP-D).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The RODQ.

RESULTS

Several Rasch analyses were performed, with 1 item deleted and 2 response categories collapsed, creating a better test without increased error. A schema for item administration and evaluation was also developed.

CONCLUSIONS

By using the abbreviated scale, suggested item order, and predicted responses, abbreviated versions of the instrument can be applied to measure LBP-D more efficiently.

Prescription of activity for low back pain: What works?

This paper provides evidence-based guidelines for the prescription of activity in the management of non-specific low back pain (NSLBP). The 62 clinical trials published between 1966 and 1997, identified by a search of the Medline and Cinahl databases, were reviewed to provide the basis for the guidelines. The available evidence suggests that physiotherapists should advise patients with acute and sub-acute NSLBP to avoid bed rest and to return to normal activity using time rather than pain as the guide to activity resumption. While structured exercise programs have not been shown to provide a benefit for acute NSLBP, there is strong evidence to support their use for patients with sub-acute and chronic NSLBP and in the prevention of NSLBP.

Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group

STUDY DESIGN

A systematic review of randomized controlled trials.

SUMMARY OF BACKGROUND DATA

The treatment of chronic low back pain is not primarily focused on removing an underlying organic disease but at the reduction of disability through the modification of environmental contingencies and cognitive processes. Behavioral interventions are commonly used in the treatment of chronic (disabling) low back pain.

OBJECTIVES

To determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific low back pain and which type of behavioral treatment is most effective.

METHODS

The authors searched the Medline and PsychLit databases and the Cochrane Controlled Trials Register up to April 1999, and Embase up to September 1999. Also screened were references of identified randomized trials and relevant systematic reviews. Methodologic quality assessment and data extraction were performed independently by two reviewers. The magnitude of effect was assessed by computing a pooled effect size for each domain (i.e., behavioral outcomes, overall improvement, back pain-specific and generic functional status, return to work, and pain intensity) using the random effects model.

RESULTS

Only six (25%) studies were high quality. There is strong evidence (level 1) that behavioral treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% confidence interval [CI] 0.25, 0.98), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI: -0.04, 0.74) and behavioral outcomes (pooled effect size 0.40; 95% CI: 0.10, 0.70) of patients with chronic low back pain when compared with waiting-list controls or no treatment. There is moderate evidence (level 2) that a addition of behavioral component to a usual treatment program for chronic low backpain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% CI: -0.01, 0.64), pain intensity (pooled effect size 0.03; 95% CI:-0.30, 0.36), and behavioral outcomes (pooled effect size 0.19; 95% CI: -0.08, 0.45).

CONCLUSIONS

Behavioral treatment seems to be an effective treatment for patients with chronic low back pain,but it is still unknown what type of patients benefit most from what type of behavioral treatment.

A randomized trial of a cognitive-behavioral program for enhancing back pain self care in a primary care setting

Back pain is a significant health care problem that has been managed unsatisfactorily in primary care settings. Providers typically address medical issues but do not adequately address patient concerns or functional limitations related to back pain. We evaluated a brief intervention for primary care back pain patients designed to provide accurate information about back pain, instill attitudes favorable towards self care, reduce fears and worries, assist patients in developing personalized action plans to manage their back pain, and improve functional outcomes. Patients enrolled in a large health maintenance organization were invited to participate in an educational program to improve back pain self care skills 6-8 weeks after a primary care back pain visit. Patients (n=226) were randomly assigned to a Self Care intervention or to Usual Care, and were assessed at baseline, 3-, 6-, and 12-months. The intervention involved a two-session Self Care group and an individual meeting and telephone conversation with the group leader, a psychologist experienced in chronic pain management. The intervention was supplemented by educational materials (book and videos) supporting active management of back pain. The control group received usual care supplemented by a book on back pain care. Participants assigned to the Self Care intervention showed significantly greater reductions in back-related worry and fear-avoidance beliefs than the control group. Modest, but statistically significant, effects on pain ratings and interference with activities were also observed.

Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group

STUDY DESIGN

A systematic review of randomized controlled trials.

SUMMARY OF BACKGROUND DATA

The treatment of chronic low back pain is not primarily focused on removing an underlying organic disease but at the reduction of disability through the modification of environmental contingencies and cognitive processes. Behavioral interventions are commonly used in the treatment of chronic (disabling) low back pain.

OBJECTIVES

To determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific low back pain and which type of behavioral treatment is most effective.

METHODS

The authors searched the Medline and PsychLit databases and the Cochrane Controlled Trials Register up to April 1999, and Embase up to September 1999. Also screened were references of identified randomized trials and relevant systematic reviews. Methodologic quality assessment and data extraction were performed independently by two reviewers. The magnitude of effect was assessed by computing a pooled effect size for each domain (i.e., behavioral outcomes, overall improvement, back pain-specific and generic functional status, return to work, and pain intensity) using the random effects model.

RESULTS

Only six (25%) studies were high quality. There is strong evidence (level 1) that behavioral treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% confidence interval [CI] 0. 25, 0.98), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI: 0.04, 0.74) and behavioral outcomes (pooled effect size 0.40; 95% CI: 0.10, 0.70) of patients with chronic low back pain when compared with waiting-list controls or no treatment. There is moderate evidence (level 2) that a addition of behavioral component to a usual treatment program for chronic low backpain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% CI: 0.01, 0.64), pain intensity (pooled effect size 0.03; 95% CI: 0.30,0.36), and behavioral outcomes (pooled effect size 0.19; 95% CI: 0.08, 0.45).

CONCLUSIONS

Behavioral treatment seems to be an effective treatment for patients with chronic low back pain,but it is still unknown what type of patients benefit most from what type of behavioral treatment.

Multimodal chronic pain rehabilitation program: its effect on immune function, depression, and health behaviors

This pilot study examined the effects of a multimodal pain rehabilitation program on the immune function, self-reported pain, depression levels, and health behaviors of patients with chronic back pain. It also estimated the relationships between self-reported pain levels, immune function, depression, and health behaviors. Data were collected at week 1 (baseline) and at week 4 (last week of treatment program) on a convenience sample of 23 patients. In general, the patients' mean T lymphocyte proliferation levels showed a decline from baseline to week 4, while natural killer cell activity showed a slight increase in cell lysis. None of the findings were statistically significant. Failure to detect significant differences may be attributed to a small effect size due to the relatively small sample size. The depression levels dropped significantly during the treatment program (p = .001). Reported levels of pain and health behaviors did not significantly change. More research is needed to determine treatment effects on immune function as well as relationships between pain levels, immune function, depression, and health behaviors in this patient population.

A cross-sectional study correlating lumbar spine degeneration with disability and pain

STUDY DESIGN

Cross-sectional design.

OBJECTIVES

To investigate the correlation between degeneration in the lumbar spine and self-reported disability and pain levels in patients with and without a history of trauma.

SUMMARY OF BACKGROUND DATA

The link between lumbar spine degeneration and low back pain remains controversial, as does the correlation between trauma and spinal degeneration.

METHODS

Radiographic and questionnaire data were collected from 172 consecutive patients with low back pain. Back pain severity was measured using two scales: one for pain over the entire episode and one for pain during the previous week. All patients also completed the Revised Oswestry Disability Questionnaire before radiography was performed. Further questions concerning the chronicity of symptoms and trauma were included.

RESULTS

Controlling for age, patients with low back pain with a history of trauma had a statistically significant increase in the severity of facet degeneration (P < 0.02) compared with nontrauma patients with low back pain. However, there was no difference in disability and pain scores between the trauma and nontrauma patients or between the genders. A weak correlation between pain severity ratings and the number of levels of degeneration and the severity of the degeneration at the disc and facets was noted.

CONCLUSIONS

Patients with low back pain with a history of trauma had more severe facet arthrosis than do nontrauma patients with low back pain, but there were no differences in pain and disability. There was a weak correlation between the quantity and severity of lumbar degeneration with pain levels, but not with disability scores. These findings are discussed in the light of recent reports regarding the cervical spine.

Behavioural treatment for chronic low back pain

BACKGROUND

The treatment of chronic low back pain is not primarily focused on removing an underlying organic pathology, but at the reduction of disability through the modification of environmental contingencies and cognitive processes. Behavioural interventions are commonly used in the treatment of chronic (disabling) low back pain.

OBJECTIVES

The objective of this systematic review was to determine if behavioural therapy is more effective than reference treatments for chronic non-specific low back pain, and which type of behavioural treatment is most effective.

SEARCH STRATEGY

We searched the Medline, PsycLit databases, and the Cochrane Controlled Trials Register up to April 1999, Embase up to September 1999. We also screened references of identified randomised trials and relevant systematic reviews.

SELECTION CRITERIA

Only randomised trials on any type of behavioural treatment for non-specific chronic low back pain were included.

DATA COLLECTION AND ANALYSIS

Methodological quality assessment and data extraction was done by two reviewers independently. The magnitude of effect was assessed by computing a pooled effect size for each domain (i.e., behavioural outcomes, overall improvement, back pain specific and generic functional status, return to work, and pain intensity) using the random effects model.

MAIN RESULTS

Only 6 studies (25%) were high quality. There is strong evidence (level 1) that behavioural treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% CI 0.25, 0.98), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI -0.04, 0.74) and behavioural outcomes (pooled effect size 0.40; 95% CI 0.10, 0.70) of chronic low back pain patients when compared to waiting list controls or no treatment. There is moderate evidence (level 2) that an additional behavioural component to a usual treatment program for chronic low back pain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% CI - 0.01, 0.64), pain intensity (pooled effect size 0.03; 95% CI - 0.30, 0. 36) and behavioural outcomes (pooled effect size 0.19; 95% CI - 0.08, 0.45).

REVIEWER'S CONCLUSIONS

Behavioural treatment seems to be an effective treatment for chronic low back pain patients, but it is still unknown what type of patients benefit most from what type of behavioural treatment.

Einzel- und Gruppentherapie in der Behandlung chronischer Schmerzen - Gibt es Effektivitätsunterschiede?

Zusammenfassung. In der vorliegenden Studie wurde der Einfluß des Behandlungssettings (Einzel- vs. Gruppentherapie) auf die Effektivität eines ambulant durchgeführten standardisierten Schmerzbewältigungstrainings untersucht, das zusätzlich zu einer medizinischen Schmerzbehandlung angeboten wurde. Insgesamt gingen 102 Datensätze von jeweils 34 Einzel-, Gruppen- und Kontrollpatienten in die Auswertung ein. Mit der psychologischen Zusatzbehandlung konnten in beiden Settingbedingungen gegenüber der rein medizinisch behandelten Kontrollgruppe signifikante Verbesserungen in den drei Hauptvariablen ‘subjektive Beeinträchtigung’, ‘katastrophisierende Kognitionen’ und ‘Depressivität’ sowie in weiteren Erfolgsvariablen erzielt werden. Inferenzstatistisch ergeben sich keine signifikanten Settingunterschiede, allerdings weisen die Effektstärken zum Katamnesezeitpunkt in den beiden erstgenannten Merkmalen auf eine gewisse Überlegenheit des Gruppensettings hin. Hinsichtlich der ‘Depressivität’ zeigen sich keine nennenswerten Effektivitätsunterschiede, ebenso wie bei der Mehrzahl aller weiteren untersuchten Outcome-Maße. Folglich sollte zumindest bei einem Schmerzbewältigungstraining aufgrund von zeit- sowie kostenökonomischen Überlegungen der Gruppenbehandlung der Vorzug gegeben werden.

The effect of a Mensendieck exercise program as secondary prophylaxis for recurrent low back pain. A randomized, controlled trial with 12-month follow-up

STUDY DESIGN

A prospective, randomized, controlled trial with a stratification block design in which a Mensendieck exercise program was compared with the experience of a control group.

OBJECTIVE

To evaluate the effect of a Mensendieck program on the incidence of recurrent episodes of low back pain in patients with a history of the condition who currently are working.

SUMMARY OF BACKGROUND DATA

One episode of low back pain increases the risk of further episodes of the condition. The Mensendieck approach combines education and exercise. This approach has been used for many years in Scandinavia and the Netherlands. However, the effects on low back pain have not been evaluated previously in a randomized, controlled trial.

METHODS

A total of 77 men and women, mean age 39.6 years (range, 21.2-49.8 years), who had finished treatment for a low back pain episode, were stratified according to incidence of low back pain episodes and symptoms of sciatica over the preceding 3 years. The patients were assigned at random to either the Mensendieck program or a control group. The Mensendieck group received 20 group sessions of exercises and ergonomic education in 13 weeks. At 5- and 12-month follow-up examinations, the patients were assessed for recurrence of low back pain, days of sick leave, low back pain, and functional scores.

RESULTS

After 12 months, there was a significant reduction in recurrent low back pain episodes in the Mensendieck group compared with the control group (P < 0.05). There was a trend toward fewer days of sick leave because of low back pain in the Mensendieck group, but no significant differences between the groups. There was reduction in pain and improvement in function in both groups, with no significant differences between the groups.

CONCLUSIONS

A secondary prophylaxis Mensendieck exercise program of 20 group sessions significantly reduced the incidence of low back pain recurrences in a population with history of the condition. However, there were no differences between the groups with regard to days of sick leave, low back pain, and function.

Psychological approaches in pain management: what works?

Outcome studies evaluating psychological treatments for pain vary in nature and intensity. Overall, however, treatment programs that include psychological interventions have been shown to be effective in treating postoperative pain, noncardiac chest pain, fibromyalgia syndrome, and chronic back pain. Cost analyses of the treatments indicate not only the clinical efficacy but the cost-effectiveness of psychological interventions. Issues related to subject attrition, noncompliance, and individual differences in treatment response should be addressed in future studies.