Early identification and intervention in the prevention of musculoskeletal pain

Prediction of transforaminal epidural injection success in sciatica (POTEISS): a protocol for the development of a multivariable prediction model for outcome after transforaminal epidural steroid injection in patients with lumbar radicular pain due to disc herniation or stenosis

BACKGROUND

Transforaminal epidural injections (TEI) can alleviate symptoms and help to maintain physical functioning and quality of life in patients with lumbar radicular pain. We aim to develop a prediction model for patient outcome after TEI in patients suffering from unilateral lumbar radicular pain due to lumbar disc herniation (LDH) or single-level spinal stenosis (LSS). The secondary aim is to estimate short-term patient outcome differences between LDH and LSS patients, the association between psychological variables and patient outcome, the rate of additional injections, surgery and complications, and to explore the short-term cost-effectiveness of TEI.

METHODS

This study is designed as a multi-centre, observational, prospective cohort study in two large regional hospitals in the Netherlands. Patients diagnosed with unilateral lumbar radicular pain secondary to LDH or LSS and congruent with MRI findings, who are referred for TEI along usual care pathways, are eligible for study participation. A total of 388 patients with LDH or LSS will be included. A pre-defined set of demographic, clinical and radiological variables will be used as the predictors in the model. The primary outcome measure is the Numerical Rating Scale (NRS) for leg pain. Secondary outcome measures include back pain, physical functioning, perceived recovery, pain coping strategies, anxiety and depression and use of analgesics and physical therapy. Patients will be evaluated at baseline, 2 weeks and 6 weeks after treatment. NRS leg pain and Likert perceived recovery data will be used as the dependent variables in a generalized linear mixed model for prediction of TEI outcome, with internal validation of performance (explained variation) by bootstrap resampling. Cost-effectiveness for a period of 6 weeks prior to and after treatment will be performed with decision-analytic modelling.

DISCUSSION

Patients with severe lumbar radicular pain often request additional treatment when conservative care is insufficient. TEI can offer relief of symptoms. Currently, it is not possible to predict responsiveness to this treatment for individual patients. This study is designed to explore predictors that can differentiate between patients that will and will not have a positive outcome after TEI. This information may support treatment strategies for this patient group.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov database under registry number NCT04540068 on September 1, 2020.

Effects of Embodiment in Virtual Reality for Treatment of Chronic Pain: Pilot Open-Label Study

BACKGROUND

Chronic pain has long been a major health burden that has been addressed through numerous forms of pharmacological and nonpharmacological treatment. One of the tenets of modern medicine is to minimize risk while providing efficacy. Further, because of its noninvasive nature, virtual reality (VR) provides an attractive platform for potentially developing novel therapeutic modalities.

OBJECTIVE

The purpose of this study was to determine the feasibility of a novel VR-based digital therapy for the treatment of chronic pain.

METHODS

An open-label study assessed the feasibility of using virtual embodiment in VR to treat chronic pain. In total, 24 patients with chronic pain were recruited from local pain clinics and completed 8 sessions of a novel digital therapeutic that combines virtual embodiment with graded motor imagery to deliver functional rehabilitation exercises over the course of 4 weeks. Pain intensity as measured by a visual analog scale before and after each virtual embodiment training session was used as the primary outcome measure. Additionally, a battery of patient-reported pain questionnaires (Fear-Avoidance Beliefs Questionnaire, Oswestry Low Back Pain Disability Questionnaire, Pain Catastrophizing Scale, and Patient Health Questionnaire) were administered before and after 8 sessions of virtual embodiment training as exploratory outcome measures to assess if the measures are appropriate and warrant a larger randomized controlled trial.

RESULTS

A 2-way ANOVA on session × pre- versus postvirtual embodiment training revealed that individual virtual embodiment training sessions significantly reduced the intensity of pain as measured by the visual analog scale (P<.001). Perceived disability due to lower back pain as measured by the Oswestry Low Back Pain Disability Questionnaire significantly improved (P=.003) over the 4-week course of virtual embodiment regimen. Improvement was also observed on the helplessness subscale of the Pain Catastrophizing Scale (P=.02).

CONCLUSIONS

This study provides evidence that functional rehabilitation exercises delivered in VR are safe and may have positive effects on alleviating the symptoms of chronic pain. Additionally, the virtual embodiment intervention may improve perceived disability and helplessness of patients with chronic pain after 8 sessions. The results support the justification for a larger randomized controlled trial to assess the extent to which virtual embodiment training can exert an effect on symptoms associated with chronic pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04060875; https://clinicaltrials.gov/ct2/show/NCT04060875.

Preventing Pain and Stress-Related Ill-Health in Employees: A 6-Months Follow-Up of a Psychosocial Program in a Cluster Randomized Controlled Trial

Purpose Pain and stress-related ill-health are major causes of long-term disability and sick leave. This study evaluated the effects of a brief psychosocial program, which previously has been tested for an at-risk population of employees. Methods The Effective Communication within the Organization (ECO) program, where supervisors and employees were trained in communication and problem solving, was compared to an active control consisting of psychoeducative lectures (PE) about pain and stress in a cluster randomized controlled trial. First-line supervisors were randomized to ECO or PE, and a total of 191 mainly female employees with self-reported pain and/or stress-related ill-health were included. The hybrid format programs consisted of 2-3 group sessions. Sick leave data was collected from social insurance registers, before and 6-months after the program. Secondary outcomes (work ability, work limitations, pain-disability risk, exhaustion symptoms, perceived stress, perceived health, quality of life, perceived communication and support from supervisors) were assessed at baseline, post intervention, and at 6-months follow-up. Results No effects were observed on primary or secondary outcome variables. Pain symptoms were common (89%), however a lower proportion (30%) were identified as at risk for long-term pain disability, which might explain the lack of evident effects. The Covid-19 pandemic affected participation rates and delivery of intervention. Conclusion In this study, preventive effects of the ECO program were not supported. Altogether, the findings point at the importance of selecting participants for prevention based on screening of psychosocial risk. Further research on workplace communication and support, and impact on employee health is warranted.

Identifying an Optimal Cut-Off Point for Musculoskeletal Pain in the Upper Extremities to Prevent Lowered Work Performance

OBJECTIVE

This study identified when musculoskeletal pain (MSP) in the upper extremities indicates lowered work performance to gauge when secondary prevention of musculoskeletal disorders is needed.

METHODS

Seven hundred thirty-three subjects from 12 manufacturing or healthcare facilities in Washington state participated. Work performance was measured by the Disabilities of the Arm, Shoulder and Hand work module (DASH-Work). Each DASH-Work score was compared to the mean among U.S. workers to determine if workers had lowered work performance. ROC curve analysis was conducted to find the cut-off in a composite MSP index (summing MSP intensities in shoulders, elbows/forearms, and hands/wrists; range 0 to 24) to detect lowered work performance.

RESULTS

The MSP index score of 2 achieved the best balance between sensitivity (0.79) and specificity (0.69) in detecting lowered work performance.

CONCLUSIONS

To prevent reduced work performance, moderate or multisite pain may require proper management.

Health-care providers' perspectives on factors influencing return-to-work after surgery for nontraumatic conditions of the upper extremity

STUDY DESIGN

This study is a descriptive survey.

INTRODUCTION

Health care providers (HCPs) are key stakeholders who facilitate workers' return to work (RTW) following upper extremity surgery. Hand therapists play a major role in this process, yet we do not know if and/or how their perspectives differ from other HCPs.

PURPOSE OF THE STUDY

This study examined HCPs' opinion on factors that influence RTW after surgery for nontraumatic upper extremity conditions and whether HCPs from different disciplines differed in their opinion.

METHODS

HCPs (occupational therapists, physiotherapists, hand therapists, exercise physiologists, psychologists, surgeons, and general practitioners) completed a survey rating 50 factors on a worker's ability to RTW. Each factor was scored using a 5-point Likert scale from "not" to "extremely" influential, which was later dichotomised. Agreement was indicated at 75%. The level of disagreement between disciplines was examined.

RESULTS

Respondents (n = 787) identified 20 factors being influential on RTW. They are (in order from highest to lowest) poor pain coping (the highest, >85% of respondents), postoperative psychological state, RTW self-efficacy, employer/supervisor's support, employer's unwillingness for job modification, recovery expectations, job satisfaction, suitable duties availability, whether the job can be modified, and mood disorder diagnosis. There was agreement that two factors do not influence RTW, gender, and preemployment medical assessment. There was disagreement (P < .05) between HCP disciplines on six factors (obesity, comorbidities, doctors' RTW recommendation, diagnosis, fitness, income). There were no consistent patterns with respect to which professions disagreed across all six factors. Hand therapists differed from the other disciplines for three of the factors including diagnosis, comorbidities, and doctor's recommendation for RTW.

DISCUSSION

The factors that stakeholders agreed as having the greatest influence were mainly related to the worker (pain and psychological factors) and the workplace and are amenable to RTW interventions.

CONCLUSION

Interventions facilitating RTW and future research should consider the factors identified by HCPs in this study.

Use and perceived added value of patient-reported measurement instruments by physiotherapists treating acute low back pain: a survey study among Dutch physiotherapists

BACKGROUND

This study aims to explore (i) physiotherapists' current use in daily practice of patient-reported measurement instruments (screening tools and questionnaires) for patients with acute low back pain (LBP), (ii) the underlying reasons for using these instruments, (iii) their perceived influence on clinical decision-making, and (iv) the association with physiotherapist characteristics (gender, physiotherapy experience, LBP experience, overall e-health affinity).

METHODS

Survey study among Dutch physiotherapists in a primary care setting. A sample of 650 physiotherapists recruited from LBP-related and regional primary care networks received the survey between November 2018 and January 2019, of which 85 (13%) completed it.

RESULTS

Nearly all responding physiotherapists (98%) reported using screening tools or other measurement instruments in cases of acute LBP; the Quebec Back Pain Disability Scale (64%) and the STarT Back Screening Tool (61%) are used most frequently. These instruments are primarily used to evaluate treatment effect (53%) or assess symptoms (51%); only 35% of the respondents mentioned a prognostic purpose. Almost three-quarters (72%) reported that the instrument only minimally impacted their clinical decision-making in cases of acute LBP.

CONCLUSIONS

Our survey indicates that physiotherapists frequently use patient-reported measurement instruments in cases of acute LBP, but mostly for non-prognostic reasons. Moreover, physiotherapists seem to feel that current instruments have limited added value for clinical decision-making. Possibly, a new measurement instrument (e.g., screening tool) needs to be developed that does fit the physiotherapist's needs and preferences. Our findings also suggest that physiotherapist may need to be more critical about which measurement instrument they use and for which purpose.

Experts' perspective on a definition for delayed return-to-work after surgery for nontraumatic upper extremity disorders: Recommendations and implications

STUDY DESIGN

Descriptive study.

INTRODUCTION

A delayed return to work (RTW) is often associated with poorer outcomes after a workplace injury but is ill defined.

PURPOSE OF THE STUDY

To define delayed RTW after surgery for nontraumatic upper extremity conditions.

METHODS

Experts were consulted to define delayed RTW and whether a universal time point can determine the transition from early to delayed RTW.

RESULTS

Forty-two experts defined a delayed RTW as either a worker not returning to preinjury (or similar) work within the expected time frame (45%); not returning to any type of work (36%); or recovering slower than expected (12%). Two-thirds of experts believed that universal time points to delineate delayed RTW should be avoided.

DISCUSSION

Multiple factors complicate a uniform definition of delayed RTW.

CONCLUSION

Defining delayed RTW should be individualized with due consideration to the type of work. Time-based cutoffs for outcome measurement may not be appropriate with continuous measures more appropriate in research.

LEVEL OF EVIDENCE

Decision analysis V.

Responding to social cues: An experimental paradigm exploring the link between context sensitivity and pain

Objectives

The term context sensitivity refers to whether a response is in tune with the ever changing demands of the context, while insensitivity is the lack of responding to these cues. To date, we know little about how well patients with pain respond emotionally to changes in the cues provided by the social context, that is, how emotionally context (in)sensitive they are and if this is related to problem severity. The aim of this experimental study was to test a method for determining levels of context sensitivity in individuals with subacute and chronic pain and to explore the link between context (in)sensitivity and pain‐related problems. We operationalized context (in)sensitivity as participants’ emotional responses (observed facial expressions and self‐reported affect) and pain bothersomeness in these contexts and explored the association between these context‐(in)sensitive social‐emotional responses and pain‐related problems.

Methods

Sixty‐two participants with pain were cued to talk openly about three different topics consecutively in a counterbalanced order: (1) their pain, (2) a negative non‐pain topic, and (3) a positive non‐pain topic. We measured the participants’ emotional responses (observed facial expressions and self‐reported affect) and pain bothersomeness across these contexts and explored the effect of social‐emotional responding on pain‐related problems.

Results

The results showed that, irrespective of individuals’ baseline levels of pain bothersomeness, positive affect, and negative affect, those who reacted with more negative affect and pain bothersomeness when prompted to discuss a positive topic had higher levels of pain‐related problems. Moreover, those who showed more negative facial expressions and pain bothersomeness when prompted to discuss a negative non‐pain topic also had higher levels of pain‐related problems.

Conclusions

These findings highlight a link between sensitivity to the social context and the severity of a pain problem. We showed that individuals with greater problem severity were less sensitive to social cues in their emotional responses, as compared to individuals with less pain‐related problems. As predicted, context‐insensitive responding appears to be most strongly associated with pain‐related problems when dealing with negative emotions. Although the cross‐sectional nature of the study prohibits causal conclusions, our findings demonstrate a link and future research is clearly needed to unravel the role of context sensitivity in the development of pain over time.

Pain chronification: what should a non-pain medicine specialist know?

OBJECTIVE

Pain is one of the most common reasons for an individual to consult their primary care physician, with most chronic pain being treated in the primary care setting. However, many primary care physicians/non-pain medicine specialists lack enough awareness, education and skills to manage pain patients appropriately, and there is currently no clear, common consensus/formal definition of "pain chronification".

METHODS

This article, based on an international Change Pain Chronic Advisory Board meeting which was held in Wiesbaden, Germany, in October 2016, provides primary care physicians/non-pain medicine specialists with a narrative overview of pain chronification, including underlying physiological and psychosocial processes, predictive factors for pain chronification, a brief summary of preventive strategies, and the role of primary care physicians and non-pain medicine specialists in the holistic management of pain chronification.

RESULTS

Based on currently available evidence, we propose the following consensus-based definition of pain chronification which provides a common framework to raise awareness among non-pain medicine specialists: "Pain chronification describes the process of transient pain progressing into persistent pain; pain processing changes as a result of an imbalance between pain amplification and pain inhibition; genetic, environmental and biopsychosocial factors determine the risk, the degree, and time-course of chronification."

CONCLUSIONS

Early intervention plays an important role in preventing pain chronification and, as key influencers in the management of patients with acute pain, it is critical that primary care physicians are equipped with the necessary awareness, education and skills to manage pain patients appropriately.

Development and Acceptability Assessment of a Self-Management Intervention to Prevent Acute to Chronic Pain Transition after Major Lower Extremity Trauma

PURPOSE

Transition from acute to chronic pain often occurs after major lower extremity trauma. Chronic pain has been found to negatively affect daily functioning, including the capacity to work and quality of life. Empirical data and an acceptability assessment were used to develop a self-management intervention aimed at preventing acute to chronic pain transition after major lower extremity trauma (i.e., iPACT-E-Trauma).

METHODS

Evidence from previous studies on preventive self-management interventions, combined with a biopsychosocial conceptual framework and clinical knowledge, helped define the key features of the preliminary version. Then a mixed-methods design was used to assess the acceptability of iPACT-E-Trauma by clinicians and patients.

RESULTS

The key features of the preliminary version of iPACT-E-Trauma were assessed as acceptable to very acceptable by clinicians and patients. After clinician assessment, intervention activities were simplified and session duration was reduced. Patient acceptability assessment of iPACT-E-Trauma led to the tailoring of key intervention features, based on determinants such as pain intensity and the implementation of self-management behaviors between intervention sessions. Web-based sessions were also developed to facilitate iPACT-E-Trauma delivery.

CONCLUSION

This study outlines the process involved in the development of an intervention to prevent chronic pain in patients with lower extremity trauma. Relevant information is provided to nurses and interdisciplinary teams on a self-management intervention to prevent the transition from acute to chronic pain in the trauma population.

Secondary prevention of chronic musculoskeletal pain: A systematic review of clinical trials

BACKGROUND

Chronic musculoskeletal pain disorders are highly prevalent and have high personal and societal cost. Hence, early detection and care of patients at risk of developing chronic pain is important. Risk factors are well known and screening tools exist, but much less is known about the care of at-risk patients. The aim of this study was to investigate the effectiveness of secondary prevention strategies for musculoskeletal pain.

METHODS

We performed a systematic review of clinical trials in which treatments were adjusted to the risk of chronicity in adults with acute or subacute musculoskeletal pain. Clinical trials, systematic reviews and meta-analyses published after January 1, 2000 were searched in PubMed and PEDro databases and in the reference list of relevant papers. The risk of bias was assessed by the PEDro score.

RESULTS

We identified 4807 potentially eligible articles; 13, corresponding to 9 studies, met the inclusion criteria. Most studies investigated low back pain. The overall risk of bias was moderate, mainly because of the difficulty of blinding in physiotherapy studies. As compared with a "one-size-fits-all" treatment, stratified programmes showed significant improvements in several domains of the International Classification of Functioning, Disability and Health: body structures and functions (pain, mood), activities (functional capacity), participation (return to work, quality of life), as well as environmental factors (healthcare consumption). Effect sizes were moderate. Overall, simple educational messages seemed sufficient for low-risk patients. Medium- and high-risk patients benefited from a physical reactivation programme combined with education. In high-risk patients, an additional cognitive-behavioural intervention further improved the outcome.

CONCLUSIONS

A stratified approach seems effective in reducing long-term disability in patients with musculoskeletal pain. However, more research is necessary to confirm these results.

Psychometric Properties of the Obstacles to Return-to-Work Questionnaire in a Brazilian context

Purpose To evaluate the psychometric properties of the Obstacles to Return-to-Work Questionnaire (ORTWQ) among Brazilian workers on sick-leave due to musculoskeletal disorders. Methods Confirmatory factor analysis was conducted to evaluate the factor structure validity of the ORTWQ. Model fit indices and salience of factor loadings were assessed. The convergent validity was estimated using the Average Variance Extracted (AVE) and Composite Reliability (CR). The correlational analysis was verified using the Spearman Correlation between the ORTWQ and other specific tools. Discriminant Validity, internal consistency, stability (test-retest) and floor/ceiling effect were also assessed. Results A total of 301 participants completed the ORTWQ with a mean age of 45.0 (9.9) years. After refinement, the factor structure indexes of the oblique model were [χ²/df = 1.8; CFI = 0.9; TLI = 0.9; PGFI = 0.7; PCFI = 0.8; RMSEA = 0.05 (90% CI 0.05-0.06)]. Only Depression, Physical Workload and Perceived Prognosis subscales presented suitable AVE indices: 0.63, 0.51 and 0.52 respectively. The correlations between ORTWQ and the other questionnaires were appropriate for almost all subscales. Reliability evaluation showed adequate estimates for all subscales except for the Worry Due to Sick-Leave (CR = 0.45; α = 0.44; ICC = 0.69). A higher order hierarchical model is suggested, in order to estimate an overall score to ORTWQ in a Brazilian population. Conclusions The psychometric properties of the Brazilian version of the ORTWQ were evaluated and after refinement, the validity, reliability and floor/ceiling effects indexes were suitable when applied to a sample of Brazilian workers on sick-leave due to musculoskeletal disorders. However, the factor structure presented some issues regarding convergent and discriminant validity.

Cross-Cultural Adaptation, Validity, and Reliability of the Persian Version of the Orebro Musculoskeletal Pain Screening Questionnaire

STUDY DESIGN

Observational study.

PURPOSE

To cross-culturally translate the Orebro Musculoskeletal Pain Screening Questionnaire (OMPQ) into Persian and then evaluate its psychometric properties (reliability, validity, ceiling, and flooring effects).

OVERVIEW OF LITERATURE

To the authors' knowledge, prior to this study there has been no validated instrument to screen the risk of chronicity in Persian-speaking patients with low back pain (LBP) in Iran. The OMPQ was specifically developed as a self-administered screening tool for assessing the risk of LBP chronicity.

METHODS

The forward-backward translation method was used for the translation and cross-cultural adaptation of the original questionnaire. In total, 202 patients with subacute LBP completed the OMPQ and the pain disability questionnaire (PDQ), which was used to assess convergent validity. 62 patients completed the OMPQ a week later as a retest.

RESULTS

Slight changes were made to the OMPQ during the translation/cultural adaptation process; face validity of the Persian version was obtained. The Persian OMPQ showed excellent test-retest reliability (intraclass correlation coefficient=0.89). Its internal consistency was 0.71, and its convergent validity was confirmed by good correlation coefficient between the OMPQ and PDQ total scores (r=0.72, p<0.05). No ceiling or floor effects were observed.

CONCLUSIONS

The Persian version of the OMPQ is acceptable for the target society in terms of face validity, construct validity, reliability, and consistency. It is therefore considered a useful instrument for screening Iranian patients with LBP.

Towards a preventive strategy for complaints of arm, neck and/or shoulder (CANS): the role of help seeking behaviour

Background

When developing an effective early preventive strategy for employees and students with CANS (Complaints of Arm, Neck or Shoulder, not caused by acute trauma or systemic disease), insight in help seeking behaviour and knowledge of factors associated with help seeking behaviour within the target population, is a prerequisite. The aim of this study was to examine whether perceived hindrance is associated with help seeking behaviour, specifically in employees and students identified with CANS. Additionally, the associations of factors related to functioning and participation, work-environment and demographics with help seeking behaviour were explored in these groups.

Methods

A cross-sectional survey was conducted among employees and students of two universities in the South of the Netherlands. The questionnaire included questions to assess (1) demographics, work/study and activity related factors (2) experience of CANS (3) perceived hindrance (4) help seeking behaviour. A subpopulation of the survey, consisting of those employees and students with self-reported CANS, received additional questionnaires to examine the impact of (1) participant characteristics (2) complaint and health related variables (3) functioning and participation (4) work-environment and social support, on help seeking behaviour.

Results

37.3% of the employees and 41.4% of the students reported CANS. Of these, respectively 43.3% and 45.5%, did not seek help and had no intention to seek help either. Employees and students who had not sought help reported less hindrance, less perceived disabilities and shorter duration of complaints, compared those who did seek help. Employees and students within this group who had also no intention to seek help, perceived fewer disabilities and reported shorter duration of complaints.

Conclusion

The absence of help seeking behaviour in respondents with CANS is a bottleneck for implementation of preventive strategies. In employees and students with CANS, help seeking behaviour is primarily determined by factors related to experienced hindrance. Our findings emphasize the need to tailor preventive strategies, in order to optimize screening and participation in early interventions for CANS.

Estimating the Risk of Chronic Pain: Development and Validation of a Prognostic Model (PICKUP) for Patients with Acute Low Back Pain

BACKGROUND

Low back pain (LBP) is a major health problem. Globally it is responsible for the most years lived with disability. The most problematic type of LBP is chronic LBP (pain lasting longer than 3 mo); it has a poor prognosis and is costly, and interventions are only moderately effective. Targeting interventions according to risk profile is a promising approach to prevent the onset of chronic LBP. Developing accurate prognostic models is the first step. No validated prognostic models are available to accurately predict the onset of chronic LBP. The primary aim of this study was to develop and validate a prognostic model to estimate the risk of chronic LBP.

METHODS AND FINDINGS

We used the PROGRESS framework to specify a priori methods, which we published in a study protocol. Data from 2,758 patients with acute LBP attending primary care in Australia between 5 November 2003 and 15 July 2005 (development sample, n = 1,230) and between 10 November 2009 and 5 February 2013 (external validation sample, n = 1,528) were used to develop and externally validate the model. The primary outcome was chronic LBP (ongoing pain at 3 mo). In all, 30% of the development sample and 19% of the external validation sample developed chronic LBP. In the external validation sample, the primary model (PICKUP) discriminated between those who did and did not develop chronic LBP with acceptable performance (area under the receiver operating characteristic curve 0.66 [95% CI 0.63 to 0.69]). Although model calibration was also acceptable in the external validation sample (intercept = -0.55, slope = 0.89), some miscalibration was observed for high-risk groups. The decision curve analysis estimated that, if decisions to recommend further intervention were based on risk scores, screening could lead to a net reduction of 40 unnecessary interventions for every 100 patients presenting to primary care compared to a "treat all" approach. Limitations of the method include the model being restricted to using prognostic factors measured in existing studies and using stepwise methods to specify the model. Limitations of the model include modest discrimination performance. The model also requires recalibration for local settings.

CONCLUSIONS

Based on its performance in these cohorts, this five-item prognostic model for patients with acute LBP may be a useful tool for estimating risk of chronic LBP. Further validation is required to determine whether screening with this model leads to a net reduction in unnecessary interventions provided to low-risk patients.

Development and validation of a screening tool to predict the risk of chronic low back pain in patients presenting with acute low back pain: a study protocol

INTRODUCTION

Around 40% of people presenting to primary care with an episode of acute low back pain develop chronic low back pain. In order to reduce the risk of developing chronic low back pain, effective secondary prevention strategies are needed. Early identification of at-risk patients allows clinicians to make informed decisions based on prognostic profile, and researchers to select appropriate participants for secondary prevention trials. The aim of this study is to develop and validate a prognostic screening tool that identifies patients with acute low back pain in primary care who are at risk of developing chronic low back pain. This paper describes the methods and analysis plan for the development and validation of the tool.

METHODS/ANALYSIS

The prognostic screening tool will be developed using methods recommended by the Prognosis Research Strategy (PROGRESS) Group and reported using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement. In the development stage, we will use data from 1248 patients recruited for a prospective cohort study of acute low back pain in primary care. We will construct 3 logistic regression models to predict chronic low back pain according to 3 definitions: any pain, high pain and disability at 3 months. In the validation stage, we will use data from a separate sample of 1643 patients with acute low back pain to assess the performance of each prognostic model. We will produce validation plots showing Nagelkerke R(2) and Brier score (overall performance), area under the curve statistic (discrimination) and the calibration slope and intercept (calibration).

ETHICS AND DISSEMINATION

Ethical approval from the University of Sydney Ethics Committee was obtained for both of the original studies that we plan to analyse using the methods outlined in this protocol (Henschke et al, ref 11-2002/3/3144; Williams et al, ref 11638).

A public health approach to musculoskeletal health

An ageing, physically inactive and increasingly obese population, coupled with finite health and social care resources, requires a shift from treating musculoskeletal disease when it arises to a preventive approach promoting lifelong musculoskeletal health. A public health approach to musculoskeletal health ensures that people are able to live not only long, but also well. Supporting self-management, addressing common misconceptions about the inevitability of musculoskeletal conditions, and offering brief interventions to support necessary lifestyle changes are basic public health functions that all health professionals can deliver. More specialist public health skills including needs assessment, data interpretation and service planning are also needed to deliver high quality services. These will require improvements in the data collected about musculoskeletal health nationally. A public health approach would benefit individuals through reduced pain and improved function due to musculoskeletal conditions, and wider society by minimising lost economic productivity and lowering health and social care costs.

Early psychologically informed interventions for workers at risk for pain-related disability: does matching treatment to profile improve outcome?

PURPOSE

This randomized controlled trial had two main aims. The first aim was to investigate the effect of early preventive, psychologically informed, interventions for pain-related disability. The second aim was explore whether people who are matched to an intervention specifically targeting their psychological risk profile had better outcomes than people who were not matched to interventions.

METHODS

A total of 105 participants were recruited from their workplace, screened for psychological risk factors and classified as being at risk for long-term pain-related disability. They were subgrouped into one of three groups based on their psychological profile. Three behaviorally oriented psychological interventions were developed to target each of the three risk profiles. Half of the participants were assigned a matched intervention developed to target their specific profile, and half were assigned an unmatched intervention. After treatment, repeated measure ANOVAs and v2 tests were used to determine if treatments had an effect on primary and secondary outcomes including perceived disability, sick leave, fear and avoidance, pain catastrophizing and distress, and if matched participants had better outcomes than did unmatched.

RESULTS

Treatments had effects on all outcome variables (effect sizes d ranging between 0.23 and 0.66), but matched participants did not have better outcomes than unmatched.

CONCLUSIONS

Early, preventive interventions have an impact on a number of outcome variables but it is difficult to realize a matching procedure. More in-depth research of the process of matching is needed.

The Development and Testing of a Checklist to Study Behaviour Change Techniques used in a Treatment Programme for Canadian Armed Forces Members with Chronic Non-specific Low Back Pain

PURPOSE

There are reports of increased use of a variety of behaviour change techniques (BCT) by physiotherapists and findings of beneficial effects of use. However, there is a lack of physiotherapy-specific definitions of these techniques, as well as a sense of how physiotherapists use them in practice. Through this study, the authors created and field tested a preliminary nomenclature and description for BCT in patients with chronic non-specific low back pain (CNSLBP).

METHODS

Items for the Physiotherapy Behaviour Change Technique (PT-BCT) checklist were derived from a nomenclature created for use in psychology and also from publications of studies using cognitive behaviour therapy-based approaches in physiotherapy. Content validity was tested via survey of clinical and research experts. Videotapes of a 6-week patient self-management rehabilitation programme were used for training, reliability testing, and field testing of the PT-BCT checklist.

RESULTS

Checklist items were endorsed by the majority of experts surveyed; intra- and inter-rater reliability were moderate to high. In the field study, a broad range of BCT types (behavioural, cognitive, and motivational) were observed in both classroom and gym settings.

CONCLUSIONS

The BCT nomenclature arising from this study and the PT-BCT checklist will be useful to further explore behaviour change in physiotherapy practice. The observation in this study that BCT were integrated into physiotherapists' practice illustrates how physiotherapists can play a role in changing behaviour, specifically in the presence of CNSLBP.

Evidence-informed physical therapy management of performance-related musculoskeletal disorders in musicians

Playing a musical instrument at an elite level is a highly complex motor skill. The regular daily training loads resulting from practice, rehearsals and performances place great demands on the neuromusculoskeletal systems of the body. As a consequence, performance-related musculoskeletal disorders (PRMDs) are globally recognized as common phenomena amongst professional orchestral musicians. These disorders create a significant financial burden to individuals and orchestras as well as lead to serious consequences to the musicians’ performance and ultimately their career. Physical therapists are experts in treating musculoskeletal injuries and are ideally placed to apply their skills to manage PRMDs in this hyper-functioning population, but there is little available evidence to guide specific injury management approaches. An Australia-wide survey of professional orchestral musicians revealed that the musicians attributed excessively high or sudden increase in playing-load as major contributors to their PRMDs. Therefore, facilitating musicians to better manage these loads should be a cornerstone of physical therapy management. The Sound Practice orchestral musicians work health and safety project used formative and process evaluation approaches to develop evidence-informed and clinically applicable physical therapy interventions, ultimately resulting in favorable outcomes. After these methodologies were employed, the intervention studies were conducted with a national cohort of professional musicians including: health education, onsite injury management, cross-training exercise regimes, performance postural analysis, and music performance biomechanics feedback. The outcomes of all these interventions will be discussed alongside a focussed review on the existing literature of these management strategies. Finally, a framework for best-practice physical therapy management of PRMDs in musicians will be provided.

The relationship between positive or negative phrasing and patients' coping with lateral epicondylitis

BACKGROUND

Research suggests that phrases with negative content can affect patients' response to medical procedures and how they cope with medical illnesses. We hypothesized that patients with lateral epicondylitis who describe their condition in positive phrases cope better than those who do not.

METHODS

We prospectively followed up 91 patients with lateral epicondylitis for 12 months. The patients indicated their baseline coping status based on the Pain Catastrophizing Scale (PCS) and were discharged with a wait-and-see policy. During follow-up interviews, the patients described the nature of their condition in their own words and were then categorized into either positive or negative phrasing groups. We compared these two groups regarding current coping status and whether they had sought additional treatment. We also analyzed for the factors associated with these outcomes.

RESULTS

There were no significant differences in baseline PCS scores between the two groups. At follow-up, patients in the positive phrasing group (n = 62) had significantly lower PCS scores and were less likely to seek additional treatment than those in the negative phrasing group (n = 29). Multivariable analyses showed that positive phrasing and low pain levels were independently associated with improvement in PCS scores and that negative phrasing and depression were independently associated with patients' seeking additional treatment.

CONCLUSION

Patients' positive phrasing about their condition are associated with improvement in their coping status and with less use of medical resources in the case of lateral epicondylitis. This study suggests that patients with more positive attitudes toward their illness cope and comply better when a wait-and-see treatment is recommended by their physicians.

Problematic pain - redefining how we view pain?

The term 'problematic pain' is relatively new and has been the recent source of much debate, especially among primary and community care pain clinicians. In this article, we review the concept of problematic pain, highlighting how it fits in the context of acute, sub-acute and chronic pain. We also examine how risk for the development of chronicity can be assessed using current data and screening tools. The use of ultra-short screening tools for other conditions has previously been evaluated in the literature, and we propose a new tool, to open discussion for the assessment of problematic pain. This is especially relevant in the short consultation where it can be difficult to capture meaningful information quickly. Finally, we focus upon new initiatives currently in progress in the arena of problematic pain in the United Kingdom.

Quality of life in chronic pain is more associated with beliefs about pain, than with pain intensity

OBJECTIVES

The objectives of this study were to investigate pain cognitions and quality of life of chronic pain patients referred to a multi-disciplinary university pain management clinic and to search for predictors of quality of life.

METHODS

A heterogeneous group of 1208 chronic pain patients referred to the Maastricht university hospital pain clinic participated in this cross-sectional study. At the initial assessment, all patients completed a set of questionnaires on demographic variables, cause, location, pain intensity (McGill pain questionnaire, MPQ), pain coping and beliefs (pain coping and cognition list, PCCL), pain catastrophising (pain catastrophising scale, PCS) and eight dimensions of quality of life (Rand-36).

RESULTS

The results showed that the present sample of heterogeneous pain patients reported low quality of life on each domain and significantly lower scores than has been found in previous studies with other Dutch chronic pain populations. Patients with low back pain and multiple pain localisations experienced most functional limitations. Women reported more pain, more catastrophising thoughts about pain, more disability and lower vitality and general health. When tested in a multiple regression analysis, pain catastrophising turned out to be the single most important predictor of quality of life. Especially social functioning, vitality, mental health and general health are significantly associated with pain catastrophising.

CONCLUSIONS

Patients from a multi-disciplinary university pain clinic experience strikingly low quality of life, whereby low back pain patients and patients with multiple pain localisations have the lowest quality of life. Pain catastrophising showed the strongest association with quality of life, and stronger than pain intensity.

Development of a short form of the Örebro Musculoskeletal Pain Screening Questionnaire

STUDY DESIGN

A longitudinal design where the questionnaire was completed at a pretest and predictive ability evaluated with a 1-year follow-up. A second sample was employed to provide a replication.

OBJECTIVE

The aim of the study was to validate a short form of the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMSPQ).

SUMMARY OF BACKGROUND DATA

Several studies demonstrate the research and clinical utility of the ÖMSPQ. Calls have been made for a shorter form that requires less time in administering.

METHODS

The short version was constructed by taking two items from each of the five factors shown to have predictive power. It was then tested against the long form in two samples of people with musculoskeletal pain where one reflects an occupational health care population (N = 324) and the other a primary care population (N = 183) thus providing a built-in replication. All participants completed the ÖMSPQ and were then followed over the course of a year to evaluate disability as measured by sick leave.

RESULTS

The correlation between the short and long forms was 0.91. The receiver operating characteristic curve was nearly identical for the long and short versions of the questionnaire (e.g., primary care sample: 0.84 vs. 0.81; occupational sample: 0.72 vs. 0.70). Of those who developed disability, a cutoff of 50 on the short version identified 85% in the occupational and 83% in the primary care samples which was nearly as good as the full version.

CONCLUSION

The short form of the ÖMSPQ is appropriate for clinical and research purposes, since it is nearly as accurate as the longer version.

Study protocol of cost-effectiveness and cost-utility of a biopsychosocial multidisciplinary intervention in the evolution of non-specific sub-acute low back pain in the working population: cluster randomised trial

BACKGROUND

Low back pain (LBP), with high incidence and prevalence rate, is one of the most common reasons to consult the health system and is responsible for a significant amount of sick leave, leading to high health and social costs. The objective of the study is to assess the cost-effectiveness and cost-utility analysis of a multidisciplinary biopsychosocial educational group intervention (MBEGI) of non-specific sub-acute LBP in comparison with the usual care in the working population recruited in primary healthcare centres.

METHODS/DESIGN

The study design is a cost-effectiveness and cost-utility analysis of a MBEGI in comparison with the usual care of non-specific sub-acute LBP.Measures on effectiveness and costs of both interventions will be obtained from a cluster randomised controlled clinical trial carried out in 38 Catalan primary health care centres, enrolling 932 patients between 18 and 65 years old with a diagnosis of non-specific sub-acute LBP. Effectiveness measures are: pharmaceutical treatments, work sick leave (% and duration in days), Roland Morris disability, McGill pain intensity, Fear Avoidance Beliefs (FAB) and Golberg Questionnaires. Utility measures will be calculated from the SF-12. The analysis will be performed from a social perspective. The temporal horizon is at 3 months (change to chronic LBP) and 12 months (evaluate the outcomes at long term).Assessment of outcomes will be blinded and will follow the intention-to-treat principle.

DISCUSSION

We hope to demonstrate the cost-effectiveness and cost-utility of MBEGI, see an improvement in the patients' quality of life, achieve a reduction in the duration of episodes and the chronicity of non-specific low back pain, and be able to report a decrease in the social costs. If the intervention is cost-effectiveness and cost-utility, it could be applied to Primary Health Care Centres.

TRIAL REGISTRATION

ISRCTN: ISRCTN58719694.

Prognostic factors for the effect of a myofeedback-based teletreatment service

We investigated the potential prognostic factors for clinically relevant improvements in pain intensity and pain-related disability after myofeedback-based teletreatment. Sixty-five female computer users, 56 female patients with whiplash-associated disorders and 18 female patients with non-specific neck and shoulder pain participated in the study. They received myofeedback-based teletreatment or usual treatment. Questionnaires concerning prognostic factors, pain and disability were completed before the start of the intervention (baseline) and at follow-ups at the end of the intervention, and after 3 and 6 months. Logistic regression analyses were performed in order to investigate prognostic factors for clinically relevant improvement. In the intervention group, improvement in pain intensity was predicted by baseline pain intensity. Baseline pain intensity and disability, and fear-avoidance and endurance related pain coping responses were prognostic factors for outcome in pain-related disability in this group. There were few differences between the intervention groups; fear-avoidance coping responses influenced the outcome after teletreatment only. Myofeedback-based teletreatment appears to be an useful telemedicine intervention, especially for participants with moderate to high levels of pain and disability, high perceived help/hopelessness, and those who tend to deal with their pain by avoiding social and physical activities.

Study protocol of effectiveness of a biopsychosocial multidisciplinary intervention in the evolution of non-specific sub-acute low back pain in the working population: cluster randomised trial

Background

Non-specific low back pain is a common cause for consultation with the general practitioner, generating increased health and social costs. This study will analyse the effectiveness of a multidisciplinary intervention to reduce disability, severity of pain, anxiety and depression, to improve quality of life and to reduce the incidence of chronic low back pain in the working population with non-specific low back pain, compared to usual clinical care.

Methods/Design

A Cluster randomised clinical trial will be conducted in 38 Primary Health Care Centres located in Barcelona, Spain and its surrounding areas. The centres are randomly allocated to the multidisciplinary intervention or to usual clinical care. Patients between 18 and 65 years old (n = 932; 466 per arm) and with a diagnostic of a non-specific sub-acute low back pain are included. Patients in the intervention group are receiving the recommendations of clinical practice guidelines, in addition to a biopsychosocial multidisciplinary intervention consisting of group educational sessions lasting a total of 10 hours. The main outcome is change in the score in the Roland Morris disability questionnaire at three months after onset of pain. Other outcomes are severity of pain, quality of life, duration of current non-specific low back pain episode, work sick leave and duration, Fear Avoidance Beliefs and Goldberg Questionnaires. Outcomes will be assessed at baseline, 3, 6 and 12 months. Analysis will be by intention to treat. The intervention effect will be assessed through the standard error of measurement and the effect-size. Responsiveness of each scale will be evaluated by standardised response mean and receiver-operating characteristic method. Recovery according to the patient will be used as an external criterion. A multilevel regression will be performed on repeated measures. The time until the current episode of low back pain takes to subside will be analysed by Cox regression.

Discussion

We hope to provide evidence of the effectiveness of the proposed biopsychosocial multidisciplinary intervention in avoiding the chronification of low back pain, and to reduce the duration of non-specific low back pain episodes. If the intervention is effective, it could be applied to Primary Health Care Centres.

Trial Registration

ISRCTN21392091

Prognostic factors for intervention effect on neck/shoulder symptom intensity and disability among female computer workers

INTRODUCTION

It has been suggested that treatments may be more effective when they are matched to patient characteristics. This study aimed at investigating potential prognostic factors for clinically relevant improvement in symptom intensity and symptom-related disability among employees with symptoms in the neck/shoulder area, receiving either ergonomics counseling or such counseling in combination with myofeedback training.

METHODS

A randomized controlled study was performed among female computer users aged 45 or older (n = 36). A clinical examination and a questionnaire survey were performed before inclusion in the study. Symptom intensity and disability was assessed using questionnaires before the start of the interventions (baseline) and at follow-ups directly after the end of the interventions (T0) and after 3 (T3) and 6 (T6) months. Logistic regression analyses were performed in order to assess prognostic factors for clinically relevant improvement in symptom intensity and disability.

RESULTS

Improvement in symptom intensity was consistently predicted by symptom intensity at baseline. Diagnosis and stress-induced lack of muscular rest were prognostic factors for improvement in symptom intensity at short term follow-up. Baseline disability and passive coping consistently served as prognostic factors for outcome in disability. Few substantial differences were found between the interventions in terms of prognostic factors.

CONCLUSIONS

Myofeedback training in combination with ergonomics counseling seem to be an especially beneficial tool for secondary prevention among employees with moderate levels of symptom intensity and symptom-related disability, who respond to work-related stress by increased/sustained muscle activation, and who tend to employ passive coping to deal with their neck/shoulder symptoms.

Spinal cord injury-related pain in rehabilitation: a cross-sectional study of relationships with cognitions, mood and physical function

Although psychological aspects of SCI-related pain have been investigated in those with chronic pain, little data is available regarding these factors in those early in the course of the injury. Using a sample admitted for SCI rehabilitation, this paper describes the relationships between usual pain intensity, mood, disability and both pain and SCI-related psychological factors. The sample were largely similar to other samples of individuals with SCI-related chronic pain in terms of mood, but were noted to be less catastrophic in their thinking about pain than a comparative pain clinic sample. They also reported SCI self-efficacy and acceptance scores consistent with other SCI samples. Compared with other SCI populations there were mixed findings in relation to physical disability. Consistent with previous findings in chronic pain SCI samples, usual pain intensity was found to have a strong relationship with symptoms of anxiety and depression, and pain-related life interference. SCI acceptance was significantly negatively associated with depression scores, pain catastrophizing was significantly positively associated with both anxiety and depression scores, and SCI self-efficacy was significantly negatively associated with both anxiety and depression scores. SCI self-efficacy was also significantly positively associated with physical function scores. These findings suggest that pain-related psychological factors may have importance even early in the clinical course following SCI, but that it is important, however, to consider more general SCI-related psychological factors alongside them. In addition, these findings suggest the possibility that early interventions based upon the cognitive behavioural treatment of pain may be integrated into SCI rehabilitation programmes.

Classification Accuracy of MMPI-2 Validity Scales in the Detection of Pain-Related Malingering

The purpose of this study was to determine the accuracy of Minnesota Multiphasic Personality Inventory 2nd edition (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) validity indicators in the detection of malingering in clinical patients with chronic pain using a hybrid clinical-known groups/simulator design. The sample consisted of patients without financial incentive ( n = 23), nonmalingering patients with financial incentive ( n = 34), patients definitively determined to be malingering based on published criteria ( n = 32), and college students asked to simulate pain-related disability ( n = 26). The MMPI-2 validity scales differentiated malingerers from nonmalingerers with a high degree of accuracy. Hypochondriasis and Hysteria were also effective. For all variables except Scale L, more extreme scores were associated with higher specificity. This study demonstrates that the MMPI-2 is capable of differentiating intentional exaggeration from the effects on symptom report of chronic pain, genuine psychological disturbance, and concurrent stress associated with pursuing a claim in a medico-legal context.

Psychosocial interventions for low back pain in primary care: lessons learned from recent trials

STUDY DESIGN

Workshop discussion and literature overview.

OBJECTIVE

To give an overview of the main lessons learnt from recent trials on the effectiveness of psychosocial interventions for back pain in primary care.

SUMMARY OF BACKGROUND DATA

Recently, there has been a move to provide early psychosocial interventions in primary care to prevent chronic back pain. The results of most of the randomized trials, however, show only small differences between the psychosocial intervention and active control treatments in function or other outcome measures.

METHODS

During Low Back Pain Forum 2006 in Amsterdam 3 subgroups debated possible explanations for these "negative" findings, focusing on (1) patient selection, (2) the intervention, or (3) assessment. These discussions were illustrated with evidence from the literature and with data from 2 randomized trials.

RESULTS

The workshop participants highlighted the importance of better targeting psychosocial interventions at those who are at high risk of chronic back pain, and are likely to respond to treatment. Interventions should focus on modifiable prognostic factors, and address somatic, psychological, and social aspects of the pain problem. The general consensus was that, depending on the complexity of the condition, primary care providers can be involved in the psychosocial management of back pain, but should be adequately trained. Competencies of care providers and adherence to treatment protocols should be investigated in a process evaluation. Finally, although trials have included relevant instruments to measure back pain and disability, patient assessment might be improved by measuring other factors that may mediate or modify the effects of treatment.

CONCLUSION

Despite the publication of recent "negative" results of psychosocial interventions for back pain, workshop participants remained optimistic about the importance of this line of research. Suggestions are given for a refocused research agenda on the effectiveness of psychosocial interventions for back pain in primary care.

Life events and the risk of low back and neck/shoulder pain of the kind people are seeking care for: results from the MUSIC-Norrtalje case-control study

OBJECTIVE

To expand the knowledge about the occurrence of life events, and how they affect the risk of low back and neck/shoulder pain.

DESIGN

A population-based case-control study.

SETTING

Men and women 20-59-years old, living in and not working outside the municipality of Norrtälje, Sweden, from November 1993 to November 1997.

PARTICIPANTS

Cases (n = 1,148) were defined as all subjects from the study base who sought healthcare for a new episode of low back and/or neck/shoulder pain by any of the care givers in the municipality. Controls (n = 1,700) were selected as a stratified random sample from the study base, considering sex and age. Study subjects were interviewed about life events and critical life changes. Critical life changes were defined as events that brought about a marked psychosocial change. Odds ratios (ORs) associated with different numbers of life events or critical life changes were calculated.

RESULTS

Having experienced at least two life events during the preceding 5 years was associated with an increased risk of neck/shoulder pain (OR = 1.6, 95% CI 1.1 to 2.4). At least two critical life changes were associated with an increased risk of neck/shoulder pain (OR = 1.9, 95% CI 1.3 to 2.7). In general, no associations were observed in relation to risk of low back pain.

CONCLUSION

Life events and critical life changes are of importance for the risk of neck/shoulder pain of the kind that people are seeking care for. The study provides useful information for clinical practice and for future aetiological research on neck/shoulder pain.

Predicting treatment failure in the subacute injury phase using the Orebro Musculoskeletal Pain Questionnaire: an observational prospective study in a workers' compensation system

OBJECTIVE

The goal of the present study was to examine if patient scores on a brief biopsychosocial screening questionnaire--the Orebro Musculoskeletal Pain Questionnaire (OMPQ)--could predict clinical discharge status ("fit" vs "not fit" for return to work) after a standardized 6-week physical therapy-based work conditioning program.

METHODS

The OMPQ was administered to a derivation sample of 200 injured workers with soft tissue injuries before beginning treatment. A clinical cutoff score of 147 was subsequently tested in a second validation sample of 211 injured workers.

RESULTS

The OMPQ was able to correctly predict the discharge status of 85% of claimants.

CONCLUSIONS

These results suggest that the OMPQ can facilitate clinical decision-making through early identification of individuals likely to fail a unidisciplinary physical therapy program and who may benefit from more complete biopsychosocial treatment.

Fear avoidance and prognosis in back pain: a systematic review and synthesis of current evidence

OBJECTIVE

Fear of pain, which is hypothesized to result in avoidance behavior, has been described as an obstacle to recovery in populations of patients with low back pain. However, the evidence to support the link between high levels of fear at early stages of pain and poor prognosis has yet to be systematically assessed. We undertook this review to explore current evidence and to propose further development of theoretical models.

METHODS

We performed a systematic literature review of all prospective inception cohorts of patients with acute low back pain that measured fear of pain (often described as fear avoidance) at baseline.

RESULTS

We reviewed 9 studies reported between 2001 and 2006. Several of these had acceptable/good methodology. Three studies, of which at least 1 had excellent methodology, showed no link between measures of fear at baseline and poor prognosis in the short term (3 months) or the long term (12 months). Three studies with acceptable methodology showed weak evidence for such a link, but the effect sizes were small. The only study with acceptable methodology to find a clear link suggested that fear of movement was linked to long-term pain.

CONCLUSION

Despite the prevalent focus on fear of pain at early stages of back pain, there is little evidence to link such fear states with poor prognosis. There is some evidence to suggest that fear may play a role when pain has become persistent. There is a growing consensus that distress/depression plays an important role at early stages, and clinicians should focus on these factors.

Symptoms of distress as prospective predictors of pain-related sciatica treatment outcomes

Prior studies evaluating predictors of pain-related outcomes following treatment for sciatica have been limited by methodological problems, including retrospective study design, use of unvalidated outcome measures, and short-term follow-up periods. Despite these limitations, some reports have suggested that symptoms of psychological distress may predict individual differences in pain treatment-related outcomes (e.g., higher levels of depressive and anxious symptomatology are associated with greater pain and disability after treatment). In this study, we sought to determine whether acute symptoms of depression and anxiety were prospectively associated with treatment outcomes over a 3-year follow-up period in surgically treated and non-surgically treated patients with sciatica. Patients were recruited from the practices of community-based physicians throughout the state of Maine, and underwent in-person baseline assessments, with mailed follow-up questionnaires at 3, 6, 12, 24, and 36 months. Study outcomes included patient-reported symptoms of pain and disability. For each outcome variable, we examined whether baseline mood (i.e., mood assessed prior to the initiation of treatment), as well as mood at the immediately preceding assessment point, prospectively predicted outcomes over 3 years in multivariate repeated-measures analyses. In most analyses, symptoms of depression and anxiety, both at baseline and at the preceding time point, were significant independent predictors of worse pain and function after controlling for relevant covariates. Collectively, elevated distress appears to be a significant risk factor for reduced treatment benefit (i.e., less improvement in pain and disability) over short and medium-term follow-up periods in patients with sciatica. Future research should determine whether the prospective identification and treatment of patients with high levels of distress (a "yellow flag") is associated with improved treatment outcomes.

Do psychological factors predict outcome in both low-back pain and shoulder pain?

BACKGROUND AND OBJECTIVE

Psychological factors are assumed to predict persistent or recurrent musculoskeletal pain. The influence of psychological factors in patients with low-back pain (LBP) or shoulder pain was explored to study whether there is similarity regarding the factors that predict persisting pain and disability.

METHODS

Patients presenting in primary care with a new episode of shoulder pain or non-specific (sub)acute low back pain (LBP) were enrolled in a prospective study. In both patient groups, pain catastrophising, distress, somatisation and fear-avoidance beliefs were measured at baseline. Primary outcome measures at 3 months were (1) persistent symptoms, and (2) <30% reduction in functional disability. Multivariate logistic regression analysis was used to study the associations between psychological factors and outcome.

RESULTS

A total of 587 patients with shoulder pain and 171 patients with LBP were enrolled in the study. In patients with shoulder pain, most associations of psychological factors with outcome were weak and not significant. Only in patients with longer symptom duration at baseline (>or=3 months) were higher scores on catastrophising significantly associated with persistent symptoms (p = 0.04). In patients with LBP, psychological factors were more strongly associated with poor outcome, although most associations were not significant.

CONCLUSION

Psychological factors, with the exception of fear-avoidance beliefs, are more strongly associated with persistent pain and disability in patients with LBP than in those with shoulder pain. This seems to indicate that in a primary care population the influence of psychological factors on outcome may vary across patients with different types of pain.

Screening for Yellow Flags in First-time Acute Low Back Pain: Reliability and Validity of a Norwegian Version of the Acute Low Back Pain Screening Questionnaire

OBJECTIVES

The purpose of this study was to evaluate the reliability and construct and predictive validity of the Norwegian version of the Acute Low Back Pain Screening Questionnnaire (ALBPSQ).

METHODS

A prospective study with a 12-month follow-up was conducted on 123 patients with acute low back pain (LBP) seeking help in primary health care for the first time and 50 patients with chronic LBP for more than 3 months.

RESULTS

Test-retest reliability was high with intraclass correlation coefficients of 0.90, minimal detectable change of 12 points (of a total score of 210), and coefficient of variation of 4%. Internal consistency was 0.95. Principal-components analysis revealed 3 factors explaining 49% of the variance. The ALBPSQ score correlated highly (r> or =0.60) with disability variables, moderately (0.30<r<0.60) with age, pain intensity, and psychologic, questionnaires, and weakly (r< or =0.30) with most sociodemographic and clinical variables. The ALBPSQ were significantly lower in acute compared with chronic LBP at all follow-up visits (P<0.001). Significant associations were found between high-risk and low-risk subgroups on the ALBPSQ and pain and disability variables during follow-up. Different cut-off points on the accuracy of predicting outcomes at 6 and 12 months' follow-up showed high specificity and low sensitivity with a best cut-off of 90 points.

DISCUSSION

The findings of this study provide further evidence of the utility of the ALBPSQ in clinical studies and in primary care settings (general practitioners, chiropractors, and physiotherapists) to help identify patients at risk of developing chronic LBP and disability.

Length of disability prognosis in acute occupational low back pain: development and testing of a practical approach

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Practical evaluation of a rapid prognostic screening method to predict length of disability after acute occupational low back pain (OLBP).

SUMMARY OF BACKGROUND DATA

Few studies have evaluated the prognostic value of administrative data and selected clinical variables in typical practice settings.

METHODS

Nurse case manager (NCM) input for 16 variables and 7 administrative data variables were collected for 494 OLBP cases with at least 30 days of disability. Length of disability (LOD) was ascertained by individual indemnity payment analysis. Cases were censored after accumulating 365 days of temporary total disability or if they received a lump sum settlement. Prognostic variables were evaluated by Cox proportional hazards modeling.

RESULTS

In a multivariate model, prolonged LOD was associated with older age, shorter job tenure, female gender, presence of language barriers, comorbidity, prior work absence, delayed referral, attorney involvement nonsupportive of return to work (RTW), and low RTW motivation. Although only 12% of overall variance in LOD was explained by the model, high-risk and low-risk terciles were readily distinguished.

CONCLUSIONS

In a typical setting, data collection and risk prediction by nurses or case managers are feasible and provide specific information that can be used to identify who should receive intervention, as well as some guidance on factors that should be addressed.