Are changes in fear-avoidance beliefs, catastrophizing, and appraisals of control, predictive of changes in chronic low back pain and disability?

Rasch analysis of the Italian version of fear avoidance beliefs questionnaire (FABQ-I)

PURPOSE

To perform a Rasch analysis (RA) of the Fear Avoidance Beliefs questionnaire (FABQ-I) in a sample of chronic non-specific low back pain (CLBP) patients. The RA is expected to provide information about the internal construct validity and all the single items consistency of the FABQ-I and then contributing to the knowledge about the questionnaire's clinimetric properties.

METHODS

One hundred and fifty subjects with CLBP were enrolled into the study. The FABQ-I have been studied by means of RA. The sample size needed to obtain stable person, item and rating-scale calibrations for use with the Rasch model was based on the level of error expected in the measure.

RESULTS

RA did not support the total scale as an unidimensional measure of Fear Avodiance Beliefs. Also the analysis of the Physical Activity (PA) and Word (WO) subscales as well as the attempts of manipulation failed in achieving an acceptable fit to the Rasch model.

CONCLUSION

FABQ-I may be considered to reflect a multiple psychological constructs describing scale. The raw score of the FABQ-I and changes in scores must be interpreted with caution because as a general measure of fear avoid beliefs was not supported.

Ability to discriminate between healthy and low back pain sufferers using ultrasound during maximum lumbar extension

OBJECTIVE

To analyze the ability to discriminate between healthy individuals and individuals with chronic nonspecific low back pain (CNLBP) by measuring the relation between patient-reported outcomes and objective clinical outcome measures of the erector spinae (ES) muscles using an ultrasound during maximal isometric lumbar extension.

DESIGN

Cross-sectional study with screening and diagnostic tests with no blinded comparison.

SETTING

University laboratory.

PARTICIPANTS

Healthy individuals (n=33) and individuals with CNLBP (n=33).

INTERVENTIONS

Each subject performed an isometric lumbar extension. With the variables measured, a discriminate analysis was performed using a value ≥ 6 in the Roland and Morris disability questionnaire (RMDQ) as the grouping variable. Then, a logistic regression with the functional and architectural variables was performed. A new index was obtained from each subject value input in the discriminate multivariate analysis.

MAIN OUTCOME MEASURES

Morphologic muscle variables of the ES muscle were measured through ultrasound images. The reliability of the measures was calculated through intraclass correlation coefficients (ICCs). The relation between patient-reported outcomes and objective clinical outcome measures was analyzed using a discriminate function from standardized values of the variables and an analysis of the reliability of the ultrasound measurement.

RESULTS

The reliability tests show an ICC value >.95 for morphologic and functional variables. The independent variables included in the analysis explained 42% (P=.003) of the dependent variable variance.

CONCLUSIONS

The relation between objective variables (electromyography, thickness, pennation angle) and a subjective variable (RMDQ ≥ 6) and the capacity of this relation to identify CNLBP within a group of healthy subjects is moderate. These results should be considered by clinicians when treating this type of patient in clinical practice.

Physical therapist-delivered cognitive-behavioral therapy: a qualitative study of physical therapists' perceptions and experiences

BACKGROUND

The importance of the biopsychosocial model in assessment and management of chronic musculoskeletal conditions is recognized. Physical therapists have been encouraged to develop psychologically informed practice. Little is known about the process of physical therapists' learning and delivering of psychological interventions within the practice context.

OBJECTIVE

The aim of this study was to investigate physical therapists' experiences and perspectives of a cognitive-behavioral-informed training and intervention process as part of a randomized controlled trial (RCT) involving adults with painful knee osteoarthritis.

DESIGN

A qualitative design was used. Participants were physical therapists trained to deliver pain coping skills training (PCST).

METHODS

Eight physical therapists trained to deliver PCST were interviewed by telephone at 4 time points during the 12-month RCT period. Interviews were audiorecorded, transcribed verbatim into computer-readable files, and analyzed using Framework Analysis.

RESULTS

Thematic categories identified were: training, experience delivering PCST, impact on general clinical practice, and perspectives on PCST and physical therapist practice. Physical therapists reported positive experiences with PCST and program delivery. They thought that their participation in the RCT had enhanced their general practice. Although some components of the PCST program were familiar, the therapists found delivering the program was quite different from regular practice. Physical therapists believed the PCST program, a 3- to 4-day workshop followed by formal mentoring and performance feedback from a psychologist for 3 to 6 months and during the RCT, was critical to their ability to effectively deliver the PCST intervention. They identified a number of challenges in delivering PCST in their normal practice.

CONCLUSION

Physical therapists can be trained to confidently deliver a PCST program. The physical therapists in this study believed that training enhanced their clinical practice. Comprehensive training and mentoring by psychologists was crucial to ensure treatment fidelity.

Influence of Mckenzie protocol and two modes of endurance exercises on health-related quality of life of patients with long-term mechanical low-back pain

INTRODUCTION

Long-term Mechanical Low-Back Pain (LMLBP) negatively impacts on patients' physical capacity and quality of life. This study investigated the relationship between Health-Related Quality of Life (HRQoL) and pain intensity, and the influence of static and dynamic back extensors' endurance exercises on HRQoL in Nigerian patients with LMLBP treated with the McKenzie Protocol (MP).

METHODS

A single-blind controlled trial involving 84 patients who received treatment thrice weekly for eight weeks was conducted. Participants were assigned to the MP Group (MPG), MP plus Static Back Endurance Exercise Group (MPSBEEG) or MP plus Dynamic Endurance Exercise Group (MPDBEEG) using permuted randomization. HRQoL and pain was assessed using the Short-Form (SF-36) questionnaire and Quadruple Visual Analogue Scale respectively.

RESULTS

Sixty seven participants aged 51.8 ± 7.35 years completed the study. A total drop-out rate of 20.2% was observed in the study. Within-group comparison across weeks 0-4, 4-8 and 0-8 of the study revealed significant differences in HRQoL scores (p < 0.05). Treatment Effect Scores (TES) across the groups were significantly different (p = 0.001). MPSBEEG and MPDBEEG were comparable in TES on General Health Perception (GHP) at week 4; and GHP and Physical Functioning at week 8 respectively (p > 0.05). However, MPDEEG had significantly higher TES in the other domains of the SF-36 (p = 0.001).

CONCLUSION

HRQoL in patients with LMLBP decreases with pain severity. Each of MP, static and dynamic back extensors endurance exercises significantly improved HRQoL in LMLBP. However, the addition of dynamic back extensors endurance exercise to MP led to greater improvement in HRQoL.

Exploring differences in pain beliefs within and between a large nonclinical (workplace) population and a clinical (chronic low back pain) population using the pain beliefs questionnaire

BACKGROUND

Beliefs, cognitions, and behaviors relating to pain can be associated with a range of negative outcomes. In patients, certain beliefs are associated with increased levels of pain and related disability. There are few data, however, showing the extent to which beliefs of patients differ from those of the general population.

OBJECTIVE

This study explored pain beliefs in a large nonclinical population and a chronic low back pain (CLBP) sample using the Pain Beliefs Questionnaire (PBQ) to identify differences in scores and factor structures between and within the samples.

DESIGN

This was a cross-sectional study.

METHODS

The samples comprised patients attending a rehabilitation program and respondents to a workplace survey. Pain beliefs were assessed using the PBQ, which incorporates 2 scales: organic and psychological. Exploratory factor analysis was used to explore variations in factor structure within and between samples. The relationship between the 2 scales also was examined.

RESULTS

Patients reported higher organic scores and lower psychological scores than the nonclinical sample. Within the nonclinical sample, those who reported frequent pain scored higher on the organic scale than those who did not. Factor analysis showed variations in relation to the presence of pain. The relationship between scales was stronger in those not reporting frequent pain.

LIMITATIONS

This was a cross-sectional study; therefore, no causal inferences can be made.

CONCLUSIONS

Patients experiencing CLBP adopt a more biomedical perspective on pain than nonpatients. The presence of pain is also associated with increased biomedical thinking in a nonclinical sample. However, the impact is not only on the strength of beliefs, but also on the relationship between elements of belief and the underlying belief structure.

Effectiveness of a cognitive behavioural therapy-based rehabilitation programme (Progressive Goal Attainment Program) for patients who are work-disabled due to back pain: study protocol for a multicentre randomised controlled trial

Background

Psychologically informed rehabilitation programmes such as the Progressive Goal Attainment Program (PGAP) have the potential to address pain-related disability by targeting known psychological factors that inhibit rehabilitation progress. However, no randomised controlled trials of this intervention exist and it has not been evaluated in the Irish health service context. Our objective was to evaluate the clinical efficacy and cost-effectiveness of the PGAP in a multicentre randomised controlled trial with patients who are work-disabled due to back pain.

Methods and design

Adult patients (ages 18 years and older) with nonmalignant back pain who are work-disabled because of chronic pain and not involved in litigation in relation to their pain were invited to take part. Patients were those who show at least one elevated psychosocial risk factor (above the 50^th percentile) on pain disability, fear-based activity avoidance, fatigue, depression or pain catastrophizing. Following screening, patients are randomised equally to the intervention or control condition within each of the seven trial locations. Patients allocated to the control condition receive usual medical care only. Patients allocated to the PGAP intervention condition attend a maximum of 10 weekly individual sessions of structured active rehabilitation in addition to usual care. Sessions are delivered by a clinical psychologist and focus on graded activity, goal-setting, pacing activity and cognitive-behavioural therapy techniques to address possible barriers to rehabilitation.

The primary analysis will be based on the amount of change on the Roland Morris Disability Questionnaire posttreatment. We will also measure changes in work status, pain intensity, catastrophizing, depression, fear avoidance and fatigue. Outcome measures are collected at baseline, posttreatment and 12-month follow-up. Health-related resource use is also collected pre- and posttreatment and at 12-month follow-up to evaluate cost-effectiveness.

Discussion

This study will be the first randomized controlled trial of the PGAP in chronic pain patients and will provide important information about the clinical and cost effectiveness of the programme as well as its feasibility in the context of the Irish health service.

Trial registration

Current Controlled Trials: ISRCTN61650533

Influence of kinesiophobia and catastrophizing on pain and disability in anterior knee pain patients

PURPOSE

To evaluate the prevalence and participation of catastrophizing and fear to movement beliefs on present pain and disability in anterior knee pain patients.

METHODS

A cross-sectional study on 97 patients with chronic anterior knee pain was performed in a secondary healthcare setting. Pain was measured with Visual Analogue Scale and disability with Lysholm Scale. The psychological variables anxiety, depression, pain coping strategies, catastrophizing and fear to movement beliefs were studied by using auto-administered questionnaires.

RESULTS

Patients showed a high incidence of psychological distress (anxiety and depression), kinesiophobia and catastrophizing. A moderate correlation between pain and disability was found. Among all the coping strategies, only catastrophizing correlated with pain and disability. Anxiety depression and kinesiophobia also correlated with present pain and disability. In the regression model, catastrophizing and depression explained 56 % of the variance of disability and catastrophizing alone explained 37 % of present pain.

CONCLUSION

The moderate correlation between pain and disability suggests that pain per se is not able to explain all the variability of disability. Catastrophizing and kinesiophobia are shown to be predictors of present pain and disability in anterior knee pain patients. These findings support the fear avoidance model in the genesis and persistence of pain and disability in anterior knee pain patients and open the door to a biopsychosocial perspective in the management of these patients.

LEVEL OF EVIDENCE

III.

Obesity effect on a multimodal physiotherapy program for low back pain suffers: patient reported outcome

BACKGROUND

Several studies have linked obesity to the increased likelihood of lower back pain, but there are no studies focussing on the effectiveness of a multimodal physiotherapy programme (MPP) in obese subjects who suffer from chronic non-specific lower back pain (CNLBP). The aim of this study was to compare the effectiveness of an MPP in obese (G1) (body mass index (BMI):≥30) and non-obese (G2) (BMI:<30) patients with CNLBP.

METHODS

A quasi-experimental study with pre- and post-intervention evaluations of an MPP (lasting 8 weeks) was conducted on obese and non-obese patients with CNLBP. A total of 53 people were included in the study: G1, composed of 19 patients (10 men and 9 women) with a BMI of 33.75 and a mean age of 52.94 years, and G2, composed of 34 patients (18 men and 16 women) with a mean age of 49.19 years and an average BMI of 25.56. All patients were measured to calculate pre-intervention (baseline) and post-intervention (8 weeks) changes in disability (RMQ) and health related quality of life in physical and mental health component state of SF12 and quality of life (EQ-5D and EQ-VAS).

RESULTS

Post-intervention, non-obese group shown significant high improve than obese group in disability (RMQ: 4.00), physical component state of SF-12: (-7.26) and quality of life (EQ-VAS.: -10.49).

CONCLUSIONS

In patients with CNLBP, a BMI more than or equal to 30 minimises the effects of an MPP lasting 8 weeks.

Predictors of communication preferences in patients with chronic low back pain

BACKGROUND

The objective of this exploratory study was to identify patient-related predictors of communication preferences in patients with chronic low back pain for various dimensions of patient-physician communication (patient participation and orientation, effective and open communication, emotionally supportive communication, communication about personal circumstances).

METHODS

Eleven rehabilitation centers from various parts of Germany participated in collection of data between 2009 and 2011. A total of 701 patients with chronic low back pain were surveyed at the start of rehabilitation. The patient questionnaire captured communication preferences, pain impact, pain intensity, and psychologic variables (fear avoidance beliefs, illness coherence, control beliefs, communication self-efficacy, and personality characteristics). The rehabilitation physicians filled out a documentation sheet containing information on diagnosis, inability to work, duration of the illness, and comorbidity at the beginning and end of rehabilitation. Hierarchical regression analyses were performed.

RESULTS

On average, effective, open, and patient-centered communication was very important for patients with back pain, emotionally supportive communication was important, and communication about personal circumstances was somewhat important. The variance in communication preferences explained by the predictors studied here was 8%-19%. Older patients showed a lower preference for patient-centered and open communication, but a higher preference for communication about personal circumstances. Patients with psychologic risk factors (eg, fear avoidance beliefs), extroverted patients, and patients with high self-efficacy in patient-physician interaction generally had higher expectations of the physician's communicative behavior.

CONCLUSION

Providers should take into consideration the fact that patients with back pain have a strong need for effective, open, and patient-centered communication. A flexible approach to communication needs appears to be especially important for communication about emotional and personal circumstances, because the patients differ most clearly in this respect. Personal characteristics provided only initial clues to possible preferences; for more precision, an individual assessment (by means of questionnaires or discussion) is needed.

The relationship between acceptance, catastrophizing and illness representations in chronic pain

BACKGROUND

Cognitive- and acceptance-based approaches are used to help people live with chronic pain. Little is known about how these constructs relate to each other. In this study, we examined how cognitive representations of chronic pain relate to interpersonal styles such as catastrophizing and the behavioural process of acceptance of chronic pain. This study further examined how these processes relate to emotional and physical functioning in chronic pain.

METHODS

A cross-sectional design, employing validated questionnaires, was used to measure pain, emotional and physical dysfunction, illness representations, catastrophizing and acceptance in a heterogeneous sample of 150 chronic pain sufferers.

RESULTS

The psychological variables significantly mediated the impact of pain severity on both emotional and physical dysfunction. In addition, a distinct pattern of mediation was observed. The relationship between pain and emotional dysfunction was mediated by representations of pain as a highly emotive experience and by catastrophizing; acceptance did not mediate this relationship. By contrast, the relationship between pain and physical dysfunction was mediated by acceptance and representations of high consequences of chronic pain, but not by catastrophizing.

CONCLUSIONS

Pain severity itself is a relatively poor predictor of emotional and physical dysfunction in chronic pain states. These relationships are significantly mediated by psychological variables. Different approaches to chronic pain rehabilitation emphasize different targets (changing illness representations and reducing catastrophizing vs. acceptance and behavioural activation). This cross-sectional study suggests that these processes may differentially influence outcomes, but that they are complex and overlapping. Theoretical and clinical implications are discussed.

Are fear avoidance beliefs associated with abdominal muscle activation outcome for patients with low back pain?

BACKGROUND AND PURPOSE

Activation of transversus abdominis and fear avoidance beliefs have both been related to low back pain (LBP). This exploratory study aims to investigate associations between fear avoidance beliefs at baseline and deep abdominal muscle activation after an 8-week period of supervised exercises for chronic LBP.

METHODS

A cohort of patients with chronic non-specific LBP (N = 108) enrolled in a clinical trial was studied longitudinally. Fear avoidance beliefs for physical activity and work were measured before intervention. Activation in transversus abdominis and obliquus internus abdominis during abdominal drawing-in manoeuvre and rapid arm flexion was measured by ultrasound before and after intervention. Associations between baseline fear avoidance beliefs and deep abdominal muscle activation after exercises were analysed with multiple linear regression methods.

RESULTS

High fear avoidance beliefs for physical activity (≥16 on the subscale) were negatively associated with transversus abdominis slide after the intervention period, β = -4.92 (-8.40 to -1.45). There were no associations between fear avoidance beliefs for physical activity and abdominal muscle onset, transversus abdominis or obliquus internus contraction ratio. Fear avoidance beliefs for work were not associated with any of the muscle activation parameters.

CONCLUSION

This study suggests that there is some negative association between fear avoidance beliefs for physical activity before intervention and transversus abdominis recruitment measured by lateral slide after intervention. No other significant associations between fear avoidance beliefs and abdominal muscle activation were found. We cannot exclude random findings, meaning that the results should be considered hypothesis generating for further investigations.

Pilates-based exercise for persistent, non-specific low back pain and associated functional disability: a meta-analysis with meta-regression

OBJECTIVE

The purposes of this study were to systematically review and apply regression analysis to randomised controlled trials [RCTs] that evaluated the effectiveness of Pilates exercise in improving persistent, non-specific low back pain and functional disability.

METHODS

Electronic databases were searched from January 1950 to March 2011. Articles were eligible for inclusion if they were RCTs comparing Pilates exercise with a placebo treatment [PT], minimal intervention [MI] or another physiotherapeutic treatment [APT].

RESULTS

Nine trials were included. Pilates was moderately superior to APT (pooled Effect Size [ES] weighted = -0.55, 95% confidence interval [CI] = -0.08 to -1.03) in reducing disability but not for pain relief. Pilates provided moderate to superior pain relief compared to MI (pooled ES weighted = -0.44, 95% CI = -0.09 to -0.80) and a similar decrease in disability. The statistical model used did not detect any predictor variable.

CONCLUSIONS

Due to the presence of co-interventions and the low methodological quality of some studies, these conclusions should be interpreted with caution.

Prognostic factors for recovery in chronic nonspecific low back pain: a systematic review

BACKGROUND

Few data are available on predictors for a favorable outcome in patients with chronic nonspecific low back pain (CNLBP).

PURPOSE

The aim of this study was to assess prognostic factors for pain intensity, disability, return to work, quality of life, and global perceived effect in patients with CNLBP at short-term (≤ 6 months) and long-term (>6 months) follow-up.

DATA SOURCES

Relevant studies evaluating the prognosis of CNLBP were searched in PubMed, CINAHL, and EMBASE (through March 2010). Study Selection Articles with all types of study designs were included. Inclusion criteria were: participants were patients with CNLBP (≥ 12 weeks' duration), participants were older than 18 years of age, and the study was related to prognostic factors for recovery. Fourteen studies met the inclusion criteria.

DATA EXTRACTION

Two reviewers extracted the data and details of each study.

DATA SYNTHESIS

A qualitative analysis using "level of evidence" was performed for all included studies. Data were summarized in tables and critically appraised.

LIMITATIONS

The results of the studies reviewed were limited by their methodological weaknesses.

CONCLUSIONS

At short-term follow-up, no association was found for the factors of age and sex with the outcomes of pain intensity and disability. At long-term follow-up, smoking had the same result. At long-term follow-up, pain intensity and fear of movement had no association with disability. At short-term follow-up, conflicting evidence was found for the association between the outcomes pain intensity and disability and the factor of fear of movement. At long-term follow-up, conflicting evidence was found for the factors of age, sex, and physical job demands. At long-term follow-up, conflicting evidence also was found for the association between return to work and age, sex, and activities of daily living. At baseline, there was limited evidence of a positive influence of lower pain intensity and physical job demands on return to work. No high-quality studies were found for the outcomes of quality of life and global perceived effect.

The prognostic value of catastrophizing for predicting the clinical evolution of low back pain patients: a study in routine clinical practice within the Spanish National Health Service

BACKGROUND CONTEXT

Experimental studies suggest that catastrophizing may worsen the prognosis of low back pain (LBP) and LBP-related disability and increase the risk of chronicity.

PURPOSE

To assess the prognostic value of baseline catastrophizing for predicting the clinical evolution of LBP patients in routine clinical practice and the association between the evolution of pain and catastrophizing.

STUDY DESIGN/SETTING

Prospective study in routine clinical practice of the Spanish National Health Service.

PATIENT SAMPLE

One thousand four hundred twenty-two acute and chronic adult LBP patients treated in primary and hospital care.

OUTCOME MEASURES

Pain, disability, and catastrophizing measured through validated instruments.

METHODS

Patients were managed according to routine clinical practice. Outcome measures were assessed at baseline and 3 months later. Logistic regression models were developed to estimate the association between baseline catastrophizing score and the improvement of LBP and disability, adjusting for baseline LBP and leg pain (LP) severity, disability, duration of the pain episode, workers' compensation coverage, radiological findings, failed back surgery, and diagnostic procedures and treatments undertaken throughout the study. Another model was developed to estimate the association between the evolution of LBP and the change in catastrophizing, adjusting for the same possible confounders plus the evolution of LP and disability. Models were repeated excluding the treatments undergone after the baseline assessment.

RESULTS

Regression models showed that the degree of baseline catastrophizing does not predict the evolution of LBP and disability. Conversely, as the degree of pain improvement increases, so does the odds ratio for improvement in catastrophizing, ranging from three (95% confidence interval [95% CI], 2.00-4.50; p<.001) for improvements in pain between 1.1 and 4 visual analog scale (VAS) points, to 7.3 (95% CI, 3.49-15.36; p<.001) for improvements in pain more than 6.1 VAS points. Similar results were obtained when treatments were excluded from the models.

CONCLUSIONS

In routine practice, assessing the baseline score for catastrophizing does not help clinicians to predict the evolution of LBP and disability at 3 months.

A short, intensive cognitive behavioral pain management program reduces health-care use in patients with chronic low back pain: two-year follow-up results of a prospective cohort

PURPOSE

Cognitive behavioral interventions are recommended as non-invasive treatment options for patients with chronic low back pain (CLBP). However, most treatment effects are small and short-lived. Although a 2-week intensive pain management program for patients with CLBP seems to be effective, the long-term results are not known. The purpose of this study is to evaluate the stability of the 2-year follow-up results and whether this is reflected in the use of health-care services.

METHODS

A prospective cohort study was performed. Pre-treatment characteristics of patients and data of outcomes obtained at 1-year follow-up were used. At 2-year follow-up a structured interview was conducted following the principles of a post-marketing survey. Outcomes included daily functioning, quality of life, current intensity of pain, disturbance of pain during daily activities, and indicators of the use of pain medication and health-care services.

RESULTS

Of the 90 eligible patients 85 (94%) participated in the post-marketing survey. The 1-year clinical relevant effects are maintained at 2-year follow-up. Effect sizes for functioning and quality of life were large. More than 65% reached preset minimal clinically important differences. At pre-treatment all patients consulted their general practitioner (GP) and medical specialist (MS). At 2-year follow-up 73% reported having consulted neither a GP nor an MS during the previous year. Most of the patients indicated not to use any pain medication (57%) and the percentage patients using opioids have decreased (14%). Moreover, 81% reported to be at work.

CONCLUSIONS

The gained results from selected and motivated patients with longstanding CLBP at 1-year follow-up are stable at 2-year follow-up. Above all, most of the participants are at work and results indicate that the use of both pain medication and health care have decreased substantially.

How well do observed functional limitations explain the variance in Roland Morris scores in patients with chronic non-specific low back pain undergoing physiotherapy?

PURPOSE

Self-rated activity limitations in patients with non-specific chronic low back pain (cLBP) do not correlate well with performance in traditional tests of impairment (e.g. back strength, ROM, etc.). Tests using more "functional activities" have therefore been recommended as alternative "objective" outcome measures. We examined the relationship between a battery of such tests and self-reported activity limitations, before and in response to physiotherapy, and the influence of psychological factors on the relationship.

METHODS

37 patients with cLBP took part (45 ± 12 years; 23 female, 14 male); 32 completed 9 weeks' physiotherapy. Before and after therapy, the patients completed the Roland Morris (RM) disability questionnaire and questionnaires to assess fear avoidance beliefs, catastrophising and psychological disturbance. They also performed eight simple functional tests (stair climb, prolonged flexion, stand to floor, lift test, sock test, roll-up test, pick-up test, fingertip-to-floor test).

RESULTS

Baseline RM scores were significantly (p < 0.05) correlated with all but one of the functional test scores (ranging from r = -0.34 (half-flexion) to 0.56 (pick-up test), and with a functional test index score for all tests together (r = 0.60, p < 0.0001). The correlation between the change-scores (after treatment) for RM and for the functional test index was 0.55 (p = 0.001). Psychological factors explained 7-23 % variance in RM scores (baseline, post-therapy, and change scores), beyond that which was explained by the functional tests. Effect sizes for patients with a self-rated "good global outcome" were 1.23 for RM and 0.75 for the functional test index; for those with a "poor outcome", they were -0.08 and 0.23, respectively.

CONCLUSION

Moderately high correlations (for both absolute and change scores) were observed between the subjective and observed measures of activity limitation. This indicates that to some extent they are assessing the same underlying construct, but it also suggests that each is delivering a certain amount of unique information. Psychological factors explained some of the discrepancy between the two types of measure. Both were responsive to therapy, and their change scores reflected well the patients' global outcome ratings. The two methods of assessing activity limitations should serve to complement one another in the assessment of treatment outcome.

Pain-related fear in low back pain: A prospective study in the general population

A cognitive behavioural account of chronic low back pain (CLBP) proposes that the relationship between pain catastrophizing and functional disability is mediated by fear of movement/(re)injury. Several clinical studies already demonstrated the contribution of pain catastrophizing and fear of movement/(re)injury in the development and maintenance of CLBP. This study included people with low back pain (LBP) in the general population, and aimed to investigate whether fear of movement/(re)injury mediated the relationship between pain catastrophizing and functional disability, by examining several prerequisites for mediation. Data from the Dutch population-based Musculoskeletal Complaints and Consequences Cohort (DMC(3)) study were used, including 152 people suffering from LBP who completed both a follow-up questionnaire and a baseline questionnaire 6 months previously. This study was unable to demonstrate that the relationship between pain catastrophizing and functional disability was mediated by fear of movement/(re)injury, since the prerequisite that pain catastrophizing and functional disability were related, was not fulfilled. However, pain catastrophizing was significantly related to fear of movement/(re)injury 6 months later, above and beyond other contributing variables such as fear of movement/(re)injury already present at baseline. On its turn, fear of movement/(re)injury was related to functional disability, in addition to pain intensity. Although this study leaves some indistinctness concerning the actual relationships between pain catastrophizing, fear of movement/(re)injury, and functional disability, it does provide some evidence for the contributing role of these factors in LBP in the general population.

Cognitive assessment of musculoskeletal pain with a newly validated Greek version of the Fear-Avoidance Beliefs Questionnaire (FABQ)

Fear of pain and avoidance are psychological factors of primary importance when assessing chronic musculoskeletal pain, which are often measured with the Fear-Avoidance Beliefs Questionnaire (FABQ). Both two- and three-subscale versions have been described. The aims of this study were: to assess the cognitive traits of musculoskeletal pain patients using a newly validated Greek version of the FABQ, and to further examine the construct validity and responsiveness of the measure. Factor analysis yielded three factors that accounted for 65% of the total variance. Physical activity explained 12.3% of the variance and was identical to the original version, unlike the work subscale which split into two: the FABQ work1 related to "work as cause" (15.2% of the variance) and the FABQ work2 related to "work as prognosis" (37.5% of the variance). Internal consistency was good (0.72-0.90). Test-retest reliability was satisfactory and close to the original version both for individual items and the subscales. Responsiveness of the 3-factor model was satisfactorily assessed as the ability to detect: (A) change in general - (paired t test, effect size); (B) clinically important change (paired t test, standardised effect size), and (C) real change in the concept being measured (ROC analysis). Construct validity of the FABQ was shown through the interaction with anxiety and depression, pain control and responsibility, psychological distress and pain intensity, and criterion-related validity through the association with another fear-avoidance measure (TSK). New aspects of responsiveness and construct validity were demonstrated for the FABQ, using a three-subscale validated Greek version.

Development of and recovery from short- and long-term low back pain in occupational settings: A prospective cohort study

Using the data of the EuroBack Unit prospective cohort study, this paper investigated the role of work-related physical factors and psychological variables in predicting the development of and recovery from short-term and long-term LBP. At baseline, 1294 predominantly male industrial workers from 10 companies in Belgium and the Netherlands filled in questionnaires. At follow-up, data from 812 employees were available. Odds ratios (ORs) were calculated using simple and multiple logistic regression analyses. For those workers reporting 0 days LBP in the year prior to baseline, negative affectivity (OR 1.06, 95% CI 1.01-1.11) was a risk factor for the development of short-term LBP (=1-30 days total of LBP in the year prior to follow-up). For those who reported 1-30 days total of LBP in the year prior to baseline, only high fear of (re)injury due to movement (OR 1.07, 95% CI 1.02-1.12) increased the risk for failure to recovery from short-term LBP. For the development of long-term LBP (=more than 30 days total of LBP in the year prior to follow-up), a significant increased risk was observed among workers with high pain severity (OR 1.19, 95% CI 1.01-1.40) and with pain referred to the ankles or feet (OR 2.92, 95% CI 1.09-7.83). The risk was reduced by social support of co-workers (OR 0.73, 95% CI 0.59-0.92) and by manual handling of materials (OR 0.63, 95% CI 0.46-0.85). For those who reported more than 30 days total of LBP in the year prior to baseline, high pain severity (OR 1.18, 95% CI 1.04-1.34) increased the risk for failure to recovery from long-term LBP. Results are compared to the baseline study (Gheldof et al., 2005) and discussed in relation with prospective studies.

Barriers to rehabilitation and return to work for unemployed chronic pain patients: A qualitative study

This paper explores the perceived barriers to return to work presented by unemployed patients with chronic musculoskeletal pain. The findings are based on one to one in depth semi-structured interviews conducted with patients from four sites in the UK. Interview data were recorded from 38 patients (15 male, 23 female) aged between 29 and 62 years the sample included patients who had participated in a vocational rehabilitation scheme, those who had refused to participate and a nai ve group. Patients were in receipt of long-term social welfare benefits (incapacity benefits) and recruited via local Job Centres. The mean duration of work absence was over 5 years. The data was transcribed and analysed by means of thematic analysis. Several themes were identified as barriers to return to work from the data including pain related issues, uncertainty (both financial and physical), the healthcare system, interaction with benefits providers, perceptions of employers and personal limitations. The uncertainty and the pain condition itself were the overarching barriers from which other obstacles stemmed. This is the first qualitative study of long term unemployed benefit recipients with chronic pain. Others authors have reported psychosocial factors as barriers to work among disabled populations however, this qualitative study has identified barriers specific to unemployed chronic pain patients. The themes identified will help with the planning and development of future initiatives for returning chronic pain patients to employment.

Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients

This study aimed to determine whether self-efficacy beliefs mediated the relation between pain-related fear and pain, and between pain-related fear and disability in CLBP patients who exhibited high pain-related fear. In a cross-sectional design, 102 chronic low back pain (CLBP) patients completed measures for pain, disability, self-efficacy and pain-related fear (fear of movement and catastrophizing). Multistep regression analyses were performed to determine whether self-efficacy mediated the relation between pain-related fear and outcome (pain and/or disability). Self-efficacy was found to mediate the relation between pain-related fear and pain intensity, and between pain-related fear and disability. Therefore, this study suggests that when self-efficacy is high, elevated pain-related fear might not lead to greater pain and disability. However, in instances where self-efficacy is low, elevated pain-related fear is likely to lead to greater pain and disability. In view of these findings, we conclude that it is imperative to assess both pain-related fear and self-efficacy when treating CLBP patients with high pain-related fear.

The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy

The aim of this study was to determine the extent to which a number of distinct cognitive factors were differentially related to the levels of pain and disability reported by 183 chronic low back pain (CLBP) patients presenting for physiotherapy. After adjusting for demographics, the cognitive factors accounted for an additional 30% of the variance in pain intensity, with functional self-efficacy (beta=-0.40; P<0.001) and catastrophizing (beta=0.21; P<0.01) both uniquely contributing to the prediction of outcome. The cognitive factors also explained an additional 32% of the variance in disability after adjusting for demographics and pain intensity (total R(2)=0.61). Higher levels of functional self-efficacy (beta=-0.43; P<0.001) and lower levels of depression (beta=0.23; P<0.01) were uniquely related to lower levels of disability. Our findings clearly show that there is a strong association between cognitive factors and the levels of pain and disability reported by CLBP patients presenting for physiotherapy. Functional self-efficacy emerged as a particularly strong predictor of both pain intensity and disability. In view of our findings it would seem that targeting specific cognitive factors should be an integral facet of physiotherapy-based treatments for CLBP.

Factors promoting staying at work in people with chronic nonspecific musculoskeletal pain: a systematic review

PURPOSE

To identify determinants for staying at work (SAW) in workers with chronic musculoskeletal pain (CMP).

METHOD

A systematic review of factors that promote SAW in workers with CMP. We searched the databases of PubMed, EMBASE, PsycInfo, CINAHL and the Cochrane Library. We included studies reporting on working subjects without present CMP-related sick leave. A quality assessment of GRADE criteria and evidence synthesis was performed.

RESULTS

We identified five cross-sectional studies and two qualitative studies reporting on factors associated with SAW in workers with CMP. Consistent association with SAW was found for low perceived physical disability and low emotional distress (low-level evidence). Duration of pain, catastrophizing, self-esteem and marital status were not associated with SAW (low-level evidence). Qualitative studies indicated that personal adjustments and workplace interventions are important determinants for SAW (evidence not graded).

CONCLUSIONS

No high-level evidence for SAW determinants for workers with CMP was identified. Future interventions aimed at promoting SAW could consider reducing perceived physical disability and emotional distress, and promoting adjustment latitude at work, support from supervisors, and the workers' motivation and self-management skills. Further research is required because knowledge of SAW in workers with CMP is scarce, and the relevance of the subject is high.

Application of a diagnosis-based clinical decision guide in patients with low back pain

Background

Low back pain (LBP) is common and costly. Development of accurate and efficacious methods of diagnosis and treatment has been identified as a research priority. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based means to apply the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with LBP.

Methods

Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of LBP patients examined by one of three examiners trained in the application of the DBCDG.

Results

Data were gathered on 264 patients. Signs of visceral disease or potentially serious illness were found in 2.7%. Centralization signs were found in 41%, lumbar and sacroiliac segmental signs in 23% and 27%, respectively and radicular signs were found in 24%. Clinically relevant myofascial signs were diagnosed in 10%. Dynamic instability was diagnosed in 63%, fear beliefs in 40%, central pain hypersensitivity in 5%, passive coping in 3% and depression in 3%.

Conclusion

The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability and efficacy of treatment based on the DBCDG.

The usefulness of clinical measures of psychologic factors in patients with spinal pain

OBJECTIVE

The purposes of this study were to investigate whether a screening procedure could capture important psychologic factors with minimum burden to the patient and to investigate whether correlations exist among the various psychologic factors.

METHODS

A screening procedure consisting of the 11-item Tampa Scale for Kinesiophobia, a 2-question coping strategies screen, and the depression and anxiety subscales of the Bournemouth Disability Questionnaire was provided to consecutive patients with neck pain (NP) or low back pain (LBP) as part of the usual initial assessment process at a busy spine center, which includes chiropractic and physical therapy. Correlations and associations between these variables were determined.

RESULTS

Data were collected on 95 patients with NP and 260 patients with LBP. Statistically significant correlations and associations were found between all measures in both cohorts with the exception of depression and coping in patients with NP. Statistically significant associations were found among all measures in both cohorts with the exception of depression and coping and coping and fear in patients with NP.

CONCLUSION

This study showed that a screening procedure may provide useful clinical information regarding psychologic factors that are of potential relevance in patients with NP and LBP.

The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To examine differences between preoperative and postoperative fear of movement and investigate the relationship between fear of movement and pain, disability and physical health after spinal surgery for degenerative conditions.

SUMMARY OF BACKGROUND DATA

Consistent evidence supports the relationship between fear of movement and higher levels of pain and disability in various chronic pain populations. Fear of movement among patients undergoing spinal surgery for chronic pain has received little attention in the literature.

METHODS

Participants were 141 patients treated with surgery for lumbar and cervical degenerative conditions. Assessments were conducted before surgery and 6 weeks and 3 months after hospitalization. Fear of movement was measured with the Tampa Scale for Kinesiophobia and outcomes were measured with the Brief Pain Inventory, Oswestry or Neck Disability Index, and 12-Item Short Form Health Survey (SF-12).

RESULTS

Follow-up rates were 91% and 87% for 6 weeks and 3 months, respectively. Fear of movement beliefs improved after surgery, but 49% of patients continued to have high fear of movement at 6-week follow-up and 39% at 3-month follow-up. Patients with higher levels of fear of movement had poorer postoperative outcomes. Multilevel linear regression analyses found that postoperative fear of movement was independently associated with postoperative pain intensity, pain interference, disability, and physical health (P < 0.001), after controlling for depression, age, sex, education, race, comorbidities, type and area of surgery, prior surgeries, and baseline outcome score. Preoperative fear of movement was not predictive of poorer surgical outcomes.

CONCLUSION

Results demonstrate that postoperative but not preoperative fear of movement beliefs explain unique and significant variance in postoperative pain, disability, and physical health. Clinicians interested in improving surgical outcomes should address postoperative fear of movement along with other traditional clinical and medical risk factors. Recommendations include postoperative screening for high fear of movement beliefs and incorporating cognitive-behavioral techniques into postoperative rehabilitation for at-risk surgical spine patients.

Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction

BACKGROUND

Evidence in the musculoskeletal rehabilitation literature suggests that psychosocial factors can influence pain levels and functional outcome.

OBJECTIVE

The purpose of this study was to examine changes in select psychosocial factors and their association with knee pain and function over 12 weeks after anterior cruciate ligament (ACL) reconstruction.

DESIGN

This was a prospective, longitudinal, observational study.

METHODS

Patients with ACL reconstruction completed self-report questionnaires for average knee pain intensity (numeric rating scale [NRS]), knee function (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF]), and psychosocial factors (pain catastrophizing [Pain Catastrophizing Scale], fear of movement or reinjury [shortened version of the Tampa Scale for Kinesiophobia (TSK-11)], and self-efficacy for rehabilitation tasks [modified Self-Efficacy for Rehabilitation Outcome Scale (SER)]). Data were collected at 4 time points after surgery (baseline and 4, 8, and 12 weeks). Repeated-measures analyses of variance determined changes in questionnaire scores across time. Hierarchical linear regression models were used to examine the association of psychosocial factors with knee pain and function.

RESULTS

Seventy-seven participants completed the study. All questionnaire scores changed across 12 weeks. Baseline psychosocial factors did not predict the 12-week NRS or IKDC-SKF score. The 12-week change in modified SER score predicted the 12-week change in NRS score (r(2)=.061), and the 12-week change in modified SER and TSK-11 scores predicted the 12-week change in IKDC-SKF score (r(2)=.120).

LIMITATIONS

The psychometric properties of the psychosocial factor questionnaires are unknown in people with ACL reconstruction. The study focused on short-term outcomes using only self-report measures.

CONCLUSIONS

Psychosocial factors are potentially modifiable early after ACL reconstruction. Baseline psychosocial factor levels did not predict knee pain or function 12 weeks postoperatively. Interventions that increase self-efficacy for rehabilitation tasks or decrease fear of movement or reinjury may have potential to improve short-term outcomes for knee pain and function.

Application of a diagnosis-based clinical decision guide in patients with neck pain

BACKGROUND

Neck pain (NP) is a common cause of disability. Accurate and efficacious methods of diagnosis and treatment have been elusive. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based guide in applying the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with NP.

METHODS

Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of NP patients examined by one of three examiners trained in the application of the DBCDG.

RESULTS

Data were gathered on 95 patients. Signs of visceral disease or potentially serious illness were found in 1%. Centralization signs were found in 27%, segmental pain provocation signs were found in 69% and radicular signs were found in 19%. Clinically relevant myofascial signs were found in 22%. Dynamic instability was found in 40%, oculomotor dysfunction in 11.6%, fear beliefs in 31.6%, central pain hypersensitivity in 4%, passive coping in 5% and depression in 2%.

CONCLUSION

The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability, validity and efficacy of treatment based on the DBCDG.

Rehabilitation outcomes for orthopaedic trauma individuals as measured by the INTERMED

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

Early predictors of the long-term outcome of low back pain--results of a 22-year prospective cohort study

BACKGROUND

poor outcome of low back pain in patients seen in general practice is related to the pain history, physical impairment and working conditions, at least in short-term follow-ups. We do not know if these findings hold, seen from the perspective of decades.

OBJECTIVES

to show if patients consulting the GP for the first time regarding an episode of low back pain have excess poor outcome 22 years later and, if so, whether the best predictors are data based on the symptoms, clinical signs or work history. The design of the study is a 22-year follow-up of an inception cohort of 78 patients with low back pain. The setting of the study is a single general practice in a suburb of Copenhagen, Denmark.

METHODS

selected predictors were separated into pain characteristics, clinical signs and indicators related to the work history. Outcome measures were the 1-year period prevalence of low back pain, use of painkillers for low back pain, use of health care providers, impairments due to low back pain and unfitness for work caused by low back pain. The influence of the predictors was assessed by relative risks.

RESULTS

after 22 years, four out of five patients still experienced low back pain. The perception of poor working conditions correlates with recurrent low back pain, intake of painkillers and limitations to daily life.

CONCLUSION

compared with pain history and clinical findings, the perception of workload is a better predictor of the long-term outcome of low back pain.

Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain

STUDY DESIGN

Quasi-experimental clinical trial.

OBJECTIVES

This study compared outcomes from graded exercise and graded exposure activity prescriptions for patients participating in a multidisciplinary rehabilitation program for chronic low back pain. Our primary purpose was to investigate whether pain and disability outcomes differed based on treatment received (graded exercise or graded exposure). Our secondary purpose was to investigate if changes in selected psychological factors were associated with pain and disability outcomes.

BACKGROUND

Behavioral interventions have been advocated for decreasing pain and disability from low back pain, yet relatively few comparative studies have been reported in the literature.

METHODS

Consecutive sample with chronic low back pain recruited over a 16-month period from an outpatient chronic pain clinic. Patients received physical therapy supplemented with either graded exercise (n=15) or graded exposure (n=18) principles. Graded exercise included general therapeutic activities and was progressed with a quota-based system. Graded exposure included specific activities that were feared due to back pain and was progressed with a hierarchical exposure paradigm. Psychological measures were pain-related fear (Fear-Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia, Fear of Pain Questionnaire), pain catastrophizing (Coping Strategies Questionnaire), and depressive symptoms (Beck Depression Inventory). Primary outcome measures were pain intensity (visual analog scale) and self-report of disability (modified Oswestry Disability Questionnaire).

RESULTS

Statistically significant improvements (P<.01) were observed for pain intensity and disability at discharge. The rate of improvement did not differ based on behavioral intervention received (P>.05 for these comparisons). Overall, 50% of patients met criterion for minimally important change for pain intensity, while 30% met this criterion for disability. Change in depressive symptoms was associated with change in pain intensity, while change in pain catastrophizing was associated with change in disability.

CONCLUSIONS

Physical therapy supplemented with graded exercise or graded exposure resulted in equivalent clinical outcomes for pain intensity and disability. The overall treatment effects were modest in this setting. Instead of being associated with a specific behavioral intervention, reductions in pain and disability were associated with reductions in depressive symptoms and pain catastrophizing, respectively.

LEVEL OF EVIDENCE

Therapy, level 2b–.

Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain

Pain self-efficacy and fear of movement have been proposed to explain how pain can lead to disability for patients with chronic low back pain. However the extent to which pain self-efficacy and fear of movement mediate the relationship between pain and disability over time has not been investigated. This study aimed to investigate whether pain self-efficacy and/or fear of movement mediate the relationship between pain intensity and disability in patients with recent onset chronic low back pain. In a two-wave longitudinal design, 184 chronic low back pain patients completed measures for pain intensity, disability, pain self-efficacy and fear of movement at baseline and 12months after the onset of chronic low back pain. Regression analyses were used to test the mediational hypothesis. We found that, when measured at the same time, both pain self-efficacy and fear of movement beliefs partially mediated the effects of pain intensity on disability at the onset of chronic low back pain. However, in the longitudinal analyses, only improvements in self-efficacy beliefs partially mediated the relationship between changes in pain and changes in disability over a 12months period. We found no support for the theory that fear of movement beliefs mediate this relationship. Therefore, we concluded that pain self-efficacy may be a more important variable than fear of movement beliefs in terms of understanding the relationship between pain and disability.

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 efficacy of a short education program and a short physiotherapy program for treating low back pain in primary care: a cluster randomized trial

STUDY DESIGN

Cluster randomized clinical trial.

OBJECTIVE

To assess the efficacy of a short education program and short physiotherapy program for treating low back pain (LBP) in primary care.

SUMMARY OF BACKGROUND DATA

There is sparse evidence on the effectiveness of education and physiotherapy programs that are short enough to be feasible in primary care.

METHODS

Sixty-nine primary care physicians were randomly assigned to 3 groups and recruited 348 patients consulting for LBP; 265 (79.8%) were chronic. All patients received usual care, were given a booklet and received a consistent 15 minutes group talk on health education, which focused on healthy nutrition habits in the control group, and on active management for LBP in the "education" and "education + physiotherapy" groups. Additionally, in the "education + physiotherapy" group, patients were given a second booklet and a 15-minute group talk on postural hygiene, and 4 one-hour physiotherapy sessions of exercise and stretching which they were encouraged to keep practicing at home. The main outcome measure was improvement of LBP-related disability at 6 months. Patients' assessment and data analyses were blinded.

RESULTS

During the 6-month follow-up period, improvement in the "control" group was negligible. Additional improvement in the "education" and "education + physiotherapy" groups was found for disability (2.0 and 2.2 Roland Morris Questionnaire points, respectively), LBP (1.8 and 2.10 Visual Analogue Scale points), referred pain (1.3 and 1.6 Visual Analogue Scale points), catastrophizing (1.6 and 1.8 Coping Strategies Questionnaire points), physical quality of life (2.9 and 2.9 SF-12 points), and mental quality of life (3.7 and 5.1 SF-12 points).

CONCLUSION

The addition of a short education program on active management to usual care in primary care leads to small but consistent improvements in disability, pain, and quality of life. The addition of a short physiotherapy program composed of education on postural hygiene and exercise intended to be continued at home, increases those improvements, although the magnitude of that increase is clinically irrelevant.

Alexithymia and fear of pain independently predict heat pain intensity ratings among undergraduate university students

BACKGROUND

Alexithymia is a disturbance in awareness and cognitive processing of affect that is associated with over-reporting of physical symptoms, including pain. The relationship between alexithymia and other psychological constructs that are often associated with pain has yet to be evaluated.

OBJECTIVES

The present study examined the importance of alexithymia in the pain experience in relation to other integral psychological components of Turk's diathesis-stress model of chronic pain and disability, including fear of pain, anxiety sensitivity, pain avoidance and pain catastrophizing.

METHODS

Heat pain stimuli, using a magnitude estimation procedure, and five questionnaires (Anxiety Sensitivity Index, Fear of Pain Questionnaire III, Pain Catastrophizing Scale, avoidance subscale of the Pain Anxiety Symptoms Scale-20 and Toronto Alexithymia Scale-20) were administered to 67 undergraduate students (44 women) with a mean (+/- SD) age of 20.39+/-3.77 years.

RESULTS

Multiple linear regression analysis revealed that sex, fear of pain and alexithymia were the only significant predictors of average heat pain intensity (F[6, 60]=5.43; R2=0.35; P=0.008), accounting for 6.8%, 20.0% and 9.6% of unique variance, respectively. Moreover, the difficulty identifying feelings and difficulty describing feelings subscales, but not the externally oriented thinking subscale of the Toronto Alexithymia Scale-20 significantly predicted average heat pain intensity.

CONCLUSIONS

Individuals with higher levels of alexithymia or increased fear of pain reported higher average pain intensity ratings. The relationship between alexithymia and pain intensity was unrelated to other psychological constructs usually associated with pain. These findings suggest that difficulties with emotion regulation, either through reduced emotional awareness via alexithymia or heightened emotional awareness via fear of pain, may negatively impact the pain experience.

Predicting pain and disability in patients with hand fractures: comparing pain anxiety, anxiety sensitivity and pain catastrophizing

There is a range of anxiety-related constructs associated with pain and pain-related disability. Those most often examined are pain catastrophizing, pain anxiety and anxiety sensitivity. All three are conceptualized to be important in the development and maintenance of chronic pain, and are included within fear avoidance models. Surprisingly these constructs are not routinely examined together, and when they are, have been investigated in healthy individuals using experimental techniques or patients with chronic conditions. Although these constructs are also thought to be important in acute clinical pain, they tend not to been examined together in the same study. The focus of the current research was therefore to examine these three anxiety-related constructs in an acute pain setting, and examine their relative influence on both pain and pain-related functional disability. Participants were 82 patients with a hand fracture, recruited from a fracture clinic at a general hospital. They completed a battery of measures related to anxiety, pain and disability. Once controlling for injury-related variables, catastrophizing was found to predict current pain, pain-related anxiety predicted task-related pain, whereas anxiety sensitivity was (negatively) associated with disability. These findings are discussed in light of the relative role that these anxiety-related constructs have in pain and disability, as well as implications for future research.