Best candidates for cognitive treatment of illness perceptions in chronic low back pain: Results of a theory-driven predictor study

Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review

BACKGROUND AND OBJECTIVE

Chronic low back pain is pervasive, societally impactful, and current treatments only provide moderate relief. Exploring whether therapeutic elements, either unrecognised or perceived as implicit within clinical encounters, are acknowledged and deliberately targeted may improve treatment efficacy. Contextual factors (specifically, patient's and practitioner's beliefs/characteristics; patient-practitioner relationships; the therapeutic setting/environment; and treatment characteristics) could be important, but there is limited evidence regarding their influence. This research aims to review the impact of interventions modifying contextual factors during conservative care on patient's pain and physical functioning.

DATABASES AND DATA TREATMENT

Four electronic databases (Medline, CINAHL, PsycINFO and AMED) were searched from 2009 until 15th February 2022, using tailored search strategies, and resulted in 3476 unique citations. After initial screening, 170 full-text records were potentially eligible and assessed against the inclusion-exclusion criteria. Thereafter, studies were assessed for methodological quality using a modified Downs and Black scale, data extracted, and synthesised using a narrative approach.

RESULTS

Twenty-one primary studies (N = 3075 participants), were included in this review. Eight studies reported significant improvements in pain intensity, and seven in physical functioning, in favour of the contextual factor intervention(s). Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance.

CONCLUSION

This review identified influential contextual factors which may augment conservative chronic low back pain care. The heterogeneity of interventions suggests modifying more than one contextual factor may be more impactful on patients' clinical outcomes, although these findings require judicious interpretation.

Success or failure of chronic pain rehabilitation: the importance of good interaction - a qualitative study under patients and professionals

AIM

The aim of this study was to explore which factors are associated with a successful treatment outcome in chronic pain patients and professionals participating in a multidisciplinary rehabilitation program, with a specific focus on the patient-professional interaction.

METHODS

Patients (n = 16) and professionals (n = 10) were interviewed and/or observed. The transcribed interviews and observations were analyzed and themes were described.

RESULTS

Patients with a positive treatment outcome came to a shared understanding of their pain with their professional, demonstrated new learned behavior and were able to continue their learning process at home. Patients with a negative treatment outcome did not reach a shared understanding of their pain with their professional, were not able to change their behavior and wanted more help to achieve this. Both patient groups experienced organizational barriers within the treatment process. Factors associated with a high quality of patient-professional interaction included the patient experience of being taken seriously, the involvement of the professional with the patient, a clear explanation of the pain, and an open interaction between patient and professional.

CONCLUSION

This study provides insight into factors which were related to a positively or negatively experienced outcome of pain rehabilitation. A good match within the patient-professional interaction seems essential. IMPLICATIONS OF REHABILITATION: Within chronic pain rehabilitation good didactic skills and a client-centered attitude of the professional may be helpful in order to make the patient feel being taken seriously. An assessment of the patient's learning style might lead to a better fit of the patient education and training according to an individual's learning style. Relapse might be prevented by paying special attention to the integration of new behavior within important life areas as work and sports.

Cognitive treatment of illness perceptions in patients with chronic low back pain: a randomized controlled trial

BACKGROUND

Illness perceptions have been shown to predict patient activities. Therefore, studies of the effectiveness of a targeted illness-perception intervention on chronic nonspecific low back pain (CLBP) are needed.

OBJECTIVE

The purpose of this study was to compare the effectiveness of treatment of illness perceptions against a waiting list for patients with CLBP.

DESIGN

This was a prospectively registered randomized controlled trial with an assessor blinded for group allocation.

SETTING

The study was conducted in an outpatient rehabilitation clinic.

PARTICIPANTS

The participants were 156 patients (18-70 years of age) with CLBP (>3 months).

INTERVENTION

Patients were randomly assigned to either a treatment group or to a waiting list (control) group. Trained physical therapists and occupational therapists delivered 10 to 14 one-hour treatment sessions according to the treatment protocol.

MEASUREMENTS

The primary outcome measure was change in patient-relevant physical activities (patient-specific complaints questionnaire). The secondary outcome measures were changes in illness perceptions (illness perceptions questionnaire) and generic physical activity level (quebec back pain disability scale). Measurements were taken at baseline (0 weeks) and after treatment (18 weeks).

RESULTS

A baseline-adjusted analysis of covariance showed that there were statistically significant differences between intervention and control groups at 18 weeks for the change in patient-relevant physical activities. This was a clinically relevant change (19.1 mm) for the intervention group. Statistically significant differences were found for the majority of illness perception scales. There were no significant differences in generic physical activity levels.

LIMITATIONS

Longer-term effectiveness was not studied.

CONCLUSIONS

This first trial evaluating cognitive treatment of illness perceptions concerning CLBP showed statistically significant and clinically relevant improvements in patient-relevant physical activities at 18 weeks.