Mechanisms of education and graded sensorimotor retraining in people with chronic low back pain: a mediation analysis

Relationships Between Changes in Forward Bending, Pain Catastrophizing, and Pain Self-Efficacy During Cognitive Functional Therapy for People With Chronic Low Back Pain

OBJECTIVE: To investigate whether improvements in forward bending were related to reductions in pain catastrophizing (PC) and improvements in pain self-efficacy (PSE) in people with chronic low back pain (CLBP) who were undergoing cognitive functional therapy (CFT). DESIGN: Longitudinal observational study. METHODS: Two hundred sixty-one participants with CLBP received CFT. Forward bending was assessed at each treatment session over 13 weeks (average of 4.3 time points per participant [range, 1-8]). Inertial measurement units placed on T12 and S2 measured spinal range of movement (ROM) and velocity. Participants completed the Pain Catastrophizing Scale and the Pain Self-Efficacy Questionnaire online at 0, 3, 6, and 13 weeks. Multivariate, multilevel models evaluated the associations between individual rates of change over time for 3 spinal movement measures (trunk velocity, trunk ROM, and lumbar ROM) as well as PC/PSE. RESULTS: Strong correlations were observed for increased trunk velocity with reduced PC (r = -0.56; 95% confidence interval [CI]: -0.82, -0.01) and increased PSE (r = 0.63; 95% CI: 0.18, 0.87). There was no evidence of an association between changes in trunk ROM and PC (r = -0.06; 95% CI: 0.38, 0.28) or PSE (r = 0.36; 95% CI: -0.27, 0.65) as well as no evidence of an association between lumbar ROM and PC (r = -0.07; 95% CI: -0.63, 0.55) or PSE (r = 0.16; 95% CI: -0.49, 0.69). CONCLUSION: Improvements in PC and PSE were strongly correlated with increased trunk velocity-but not trunk or lumbar ROM-in people with CLBP who were undergoing CFT. These findings are consistent with CFT that explicitly trains "nonprotective" spinal movement in conjunction with positively reframing pain cognitions. J Orthop Sports Phys Ther 2025;55(4):1-11. Epub 12 March 2025. doi:10.2519/jospt.2025.13114.

The acceptability, feasibility, and usability of a virtual reality pain education and rehabilitation program for Veterans: a mixed-methods study

Introduction

Persistent pain is a leading cause of medical discharges for Veterans. Pain science education (PSE) aims to better people's understanding about pain and is effective at reducing pain and depressive symptoms in Veterans. Preliminary evidence suggests virtual reality (VR)-delivered PSE has clinical benefits for people with persistent pain. This study investigated the acceptability, feasibility, and usability for VR-PSE for Veterans with persistent pain.

Methods

Veterans (n = 7) and healthcare professionals (HCPs) experienced in treating Veterans (n = 5) participated in workshops that involved working through the VR-PSE program, online questionnaires, and a focus group. Quantitative data were analysed by descriptive statistics. Qualitative data were analysed using a framework analysis according to the Theoretical Framework of Acceptability (TFA). A mixed-methods analysis combined the quantitative and qualitative data via triangulation, with the findings presented according to the TFA domains.

Results

The VR-PSE program was considered easy to use, engaging, and adaptable for different functional capabilities. Appropriate screening for contraindications prior to using the VR-PSE program was considered important by HCPs. Both Veterans and HCPs emphasized the need for a trusting client-clinician relationship to improve the acceptability of the VR-PSE program.

Discussion

Overall, the VR-PSE program was found to be acceptable, feasible, and usable and may be a useful tool to incorporate into the clinical management of Veterans with persistent pain. Further research is needed to investigate the efficacy of VR-PSE programs on clinical outcomes for Veterans with persistent pain.

Real-world implementation of pain science education and barriers to use in private practice physiotherapy settings: an Australia-wide cross-sectional survey

ABSTRACT

Physiotherapists are critically positioned to integrate education into patient care, including pain science education (PSE) to enhance management and outcomes. Anecdotally, many physiotherapists report difficulty providing PSE in private practice settings. Here, we aimed to explore current PSE use, knowledge, and barriers to implementation. A nationwide online (Qualtrics) survey of PSE-trained Australian private practice physiotherapists assessed use, knowledge (revised Neurophysiology of Pain Questionnaire [rNPQ]), concept application, implementation barriers, and resource awareness/use/preferences, exploring associations with individual/clinic-level factors (clinical experience, PSE training, work location). A total of 278 physiotherapists (62.9% female, 39.4 [11.8] years, 15.2 [11.6] years of experience, 37.2% rural/remote) completed the survey. Pain science knowledge (rNPQ: mean 10.4 [2.2]/13) and perceived PSE competence was high, although 30% supported inaccurate PSE concepts. Pain science education training via professional development course was associated with higher knowledge relative to university training (multivariable; β = 1.337, P < 0.001). Physiotherapists reported providing PSE to 61% of patients, with patient-related barriers (expecting other treatments: 94%; previous negative/contradictory PSE experiences: 89%), clinic-level barriers (time constraints: 77%; insufficient billing schedules: 57%), and clinician-specific barriers (difficulties identifying/addressing patient maladaptive beliefs/behaviours: 53%; cultural/demographic translation challenges: 46%) reported. Fewer years of clinical experience was associated with heightened worry that providing PSE might go wrong (multivariable; β = -0.034, P = 0.010) and/or damage therapeutic relationships (multivariable; β = -0.049, P < 0.001). Physiotherapists were aware of over 100 PSE resources, with varying levels of perceived use/effectiveness, yet were largely unaware of educational strategies. Physiotherapists called for reduced complexity and greater ability to individualise PSE resources. Findings will guide improvements in PSE training/resources, to maximise physiotherapists' confidence and preparedness to effectively implement PSE.

Mechanism evaluation of a digitally enabled rehabilitation intervention for people in aged care and neurological rehabilitation: mediation analysis of the AMOUNT trial

PURPOSE

To investigate potential mechanisms of a digital rehabilitation intervention associated with improved mobility among adults undertaking rehabilitation.

MATERIALS AND METHODS

Causal mediation analysis of the AMOUNT trial (ACTRN12614000936628). Participants were randomised to digitally-enabled rehabilitation (virtual reality video games, activity monitors, and handheld computer devices prescribed by a physiotherapist) and usual care or usual care alone. Outcomes were mobility (Short Physical Performance Battery; continuous version; range 0-3), physical activity (average steps per day), and quality of life (EQ-5D-5L; utility score; range 0-1) measured at 6-months post-randomisation. Hypothesised mediators included mobility, physical activity, cognition, balance confidence, pain, activity and participation, and computer self-efficacy, assessed at 3-weeks post-randomisation.

RESULTS

216 participants with complete data were included. Three-week sit-to-stand ability mediated 6-month mobility (indirect effect 0.09 points, 95%CI 0.03-0.16), explaining 48% of the intervention's effect. Dynamic single-leg-stance balance mediated physical activity (indirect effect 345 steps per day, 95%CI 63-678) and composite mobility mediated quality of life (indirect effect 0.03 points, 95%CI 0.00-0.05).

CONCLUSION

Digital rehabilitation outcomes appear to be mediated through sit-to-stand ability, dynamic single-leg-stance balance, and overall mobility. While future research is required to better understand these mediators, our findings recommend sit-to-stand training as a core element of digital rehabilitation interventions targeting mobility.

The effectiveness of psychologically-informed physiotherapy for people with neck pain and the mediating role of illness perceptions: a replicated single-case experimental design study

PURPOSE

(1) To evaluate the effectiveness of personalised psychologically-informed physiotherapy in people with neck pain; (2) To explore the mediating role of changes in illness perceptions.

METHOD

In this replicated single-case study, 14 patients with non-specific neck pain at risk for chronicity received a personalised intervention addressing unhelpful illness perceptions and dysfunctional movement behaviour, according to principles of cognitive functional therapy. Outcomes included the mediating role of illness perceptions on overall effect, function, pain intensity and self-efficacy. Linear mixed models were used to analyse the data.

RESULTS

Repeated measurements (14-20 per patient), including a 3-months follow-up, showed a gradual improvement during and/or after psychologically-informed physiotherapy for overall effect, function, pain and to a lesser extent self-efficacy. Changes in each of the illness perception dimensions showed a mediation effect on overall effect, function and pain. When combining the dimensions "consequences," "personal control," "identity," "concern" and "emotional response," changes in illness perceptions explained approximately 35% of the improvement in overall effect.

CONCLUSION

Addressing unhelpful illness perceptions appears valuable in the management of patients with chronic or recurrent non-specific neck pain. Intervention effects extended beyond the treatment period, indicating that patients' improved understanding of their health condition continued to have a positive impact.

"I could 100% see myself getting hurt if I did it wrong": a qualitative exploration of exercise perceptions in people with chronic low back pain

PURPOSE

Traditionally, a specific "core" exercise focus has been favoured for chronic low back pain (CLBP) which contrasts holistic exercise approaches. This study aims to explore the perceptions of exercise in people with CLBP and whether exercise itself can convey implicit messages regarding its use in CLBP management in the absence of a clinical narrative.

MATERIALS AND METHODS

Participants were asked about their CLBP history, views of exercise for CLBP, and current exercise behaviours through online semi-structured interviews. Then, participants watched the interviewer perform the deadlift, Jefferson curl, and bird dog and were asked if they thought each individual exercise was beneficial for CLBP, and why. Data were analysed using reflexive thematic analysis through a critical realism and social constructivism lens.

RESULTS

All participants (n = 16) viewed all exercises as beneficial for health and pain relief, but perceived efficacy varied. "Core" exercises were deemed crucial for CLBP relief, while spinal flexion and external load were often perceived as potentially injurious. Distrust towards healthcare practitioners also influenced exercise perceptions.

CONCLUSION

People with CLBP perceive different exercises to either relieve pain or improve health. Healthcare practitioners can influence these perceptions, highlighting the need for consideration of exercise perceptions in clinical contexts.

Changes in spinal motor behaviour are associated with reduction in disability in chronic low back pain: A longitudinal cohort study with 1-year follow-up

BACKGROUND

The need to improve spinal motor behaviour in chronic low back pain (CLBP) rehabilitation remains unclear. The objective of this study was to test if changes in spinal motor behaviour were associated with changes in disability after an interdisciplinary rehabilitation program (IRP) in patients with CLBP.

METHODS

Seventy-one patients with CLBP participating in an IRP were included. Spinal motor behaviour was assessed with biomechanical (lumbar angular amplitude and velocity, erector spinae muscle activity and duration of the task), cognitive-emotional (task-specific fear [PRF]) and pain-related (movement-evoked pain [MEP]) measures during a lifting task before and after the IRP. Disability was measured before and after the IRP, and at 3-month and 1-year follow-ups.

RESULTS

After adjusting for confounders, changes in disability were significantly associated with MEP changes (β adj. = 0.49, p < 0.001) and PRF changes (β adj. = 0.36, p = 0.008), but not with changes in any of the biomechanical measures. MEP at the end of IRP was also associated with disability at 3 months (β adj. = 0.37, p = 0.001) and 1 year (β adj. = 0.42, p = 0.01). Biomechanical measures at the end of the IRP were not associated with disability, except for the duration of the task that was significantly associated with reduction of disability at 3 months (β non-adj = 0.5, p < 0.001).

CONCLUSIONS

Pain-related and cognitive-emotional measures of spinal motor behaviour were associated with reduction in disability following an IRP. Future research is needed to further investigate causal relationships between spinal motor behaviour and disability.

SIGNIFICANCE STATEMENT

This study supports a multidimensional understanding and analysis of spinal motor behaviour, integrating the cognitive-emotional, pain-related and biomechanical domains. It also supports the consideration of spinal motor behaviour as a potentially important treatment target in chronic low back pain management. Moreover, it suggests that reducing movement-evoked pain and task-specific fear may have more influence on disability than changing lumbar amplitude, lumbar angular velocity or erector muscle activity, which may have important implications for rehabilitation.

The influence of threat on visuospatial perception, affordances, and protective behaviour: A systematic review and meta-analysis

Perception has been conceptualised as an active and adaptive process, based upon incoming sensory inputs, which are modified by top-down factors such as cognitions. Visuospatial perception is thought to be scaled based on threat, with highly threatening objects or contexts visually inflated to promote escape or avoidance behaviours. This meta-analytical systematic review quantified the effect and evidence quality of threat-evoked visuospatial scaling, as well as how visuospatial scaling relates to affordances (perceived action capabilities) and behavioural avoidance/escape outcomes. Databases and grey literature were systematically searched inclusive to 10/04/24. Studies were assessed with a customised Risk of Bias form and meta-analysis was performed using a random-effects model. 12,354 records were identified. Of these, 49 experiments (n = 3027) were included in the review. There was consistent evidence that threat the of height influenced contextual perception (g = 0.66, 95% CI: 0.45, 0.88) and affordances (g = -0.43, 95% CI: -0.84, -0.03). Threatening objects were viewed as larger (g = 0.76, 95% CI: 0.26, 1.26) and as closer (g = 0.30, 95% CI: 0.17, 0.42). Bodily threat (pain) yielded conflicting effects on visuospatial perception/affordances. We conclude that threat may influence visuospatial perception and affordances. However, since behavioural measures were poorly reported, their relationship with visuospatial perception/affordances remains elusive.

It's OK to Move! Effect of a Brief Video on Community Confidence in Activity Despite Back Pain: A Randomized Trial

OBJECTIVE: To estimate the difference in confidence to become active despite low back pain in people who were exposed to one of 2 video interventions delivered on social media, compared to no intervention. DESIGN: A proof-of-concept, 3-group randomized controlled trial, in a 1:1:1 ratio. METHODS: Participants aged 18 years and over, with and without low back pain, were recruited via the social media channel Facebook, to view either a humorous video, a neutral video, or to no intervention. The videos were delivered online, explained evidence-based management for low back pain, and were designed to "go viral." The primary outcome was confidence in becoming active despite pain, measured using the Pain Self Efficacy Questionnaire (Item 10) (ranges from 0 [not at all confident] to 6 [completely confident]) immediately after watching the video. We aimed to capture the real-time impact and immediate reactions that contributed to the content's reach. RESULTS: Among 1933 randomized participants (mean [standard deviation] age: 58.9 [14.0] years, 1285 [75%] women), 1232 [70%] had low back pain and 88.8% completed the primary outcome. One thousand two hundred sixty-four participants were randomized to receive a video intervention, and 633 participants did not receive a video. On a 6-point scale, individuals exposed to either video (n = 1088) showed a mean confidence level 0.3 points higher (95% confidence interval: 0.1, 0.6) compared with no video (n = 630). CONCLUSION: Participants who viewed a brief video intervention reported a very small difference in confidence to become active despite low back pain, compared with no intervention. The difference may lack clinical relevance. J Orthop Sports Phys Ther 2024;54(6):1-8. Epub 18 April 2024. doi:10.2519/jospt.2024.12412.