Effects of gender and cognitive-behavioral management of depressive symptoms on rehabilitation outcome among inpatient orthopedic patients with chronic low back pain: a 1 year longitudinal study

Factors associated with return-to-work outcomes in inpatient rehabilitation - a systematic scoping review

Inpatient rehabilitation is common in Germany to improve return-to-work outcomes. The objective of this systematic scoping review was to identify factors associated with return-to-work outcomes in musculoskeletal, psychological and oncological health conditions to improve tailoring of rehabilitation therapies. A search was completed in Embase, Medline, PsycInfo and AMED until May 2023 for articles investigating inpatient rehabilitation including working-age patients with oncological, musculoskeletal, or psychological diseases using a quantitative design and reporting factors associated with return-to-work outcomes. Screening of all titles and abstracts was completed by one reviewer, full texts were read by two reviewers. Quality appraisal and data extraction was completed by two reviewers. Data was analysed using a narrative synthesis. Eighteen studies of moderate quality were included. The review identified a wide range of return-to-work parameters including employment status, work ability, sickness absence, retirement status and duration of employment since rehabilitation. In addition, 48 psychological, health- and work-related factors associated with return-to-work parameters were identified. Only one RCT investigated the relationship between a depression prevention intervention and a return-to-work outcome (work ability), which showed a significant effect. In addition to the depression prevention intervention, only the factor 'health literacy' could be considered modifiable and be addressed as part of an inpatient rehabilitation programme. Furthermore, gradual work reintegration programs and/or workplace interventions in addition to inpatient rehabilitation should be further explored to improve return-to-work outcomes.

Efficacy of cognitive behavioral therapy for reducing pain susceptibility and increasing social engagement in patients with chronic low back pain: A systematic review and meta-analysis

BACKGROUND

The objective of this study was to evaluate the efficacy of cognitive behavioral therapy in improving social engagement and pain susceptibility in patients with chronic low back pain (≥6 months duration).

METHODS

From the initial to January 2023, 5 databases were searched for randomized controlled trials, literature screening, quality evaluation, and data extraction were performed by 2 independent researchers throughout, Meta-analysis was performed using RevMan 5.4 software, standardized mean difference (SMD) was calculated for different indicators, and the combined experimental and control groups were calculated using random-effects models or fixed-effects models effect sizes, and forest plots were drawn to present the results.

RESULTS

A total of 16 studies containing 2527 patients with chronic nonspecific low back pain, all of whom had pain lasting longer than 6 months, were included, and after treatment, cognitive behavioral therapy (CBT) was superior to other treatments in improving social participation [SMD = -0.30, 95%CI (-0.60, -0.01), Z = 2.02, P = .04]. There was no significant difference from other treatments in improving patient depression [SMD = -0.07, 95%CI (-0.19, 0.05), Z = 1.11, P = .27] and anxiety [SMD = -0.07, 95%CI (-0.30, 0.16), Z = 0.52, P = .57]. Three papers describe the superiority of CBT over other treatments in improving sleep quality, but the metrics could not be combined due to too little literature.

CONCLUSION

CBT can improve patients' social participation and pain susceptibility to some extent, but it does not show advantages for managing negative emotions (depression, anxiety). Due to the limited number and low quality of included literature, the above findings still need to be validated by conducting a large sample of high-quality RCTs.

Insurance and Employment Status Are Correlated With the Presence of Waddell Signs

OBJECTIVE

The aim of the study was to determine whether employment or insurance status is associated with the presence and number of Waddell signs.

DESIGN

In this cross-sectional study, adult low back pain patients were seen at a tertiary academic center for thoracic or lumbar back pain, due to a degenerative condition. Frequency data were compared with contingency table analysis, including χ2 and logistic regression.

RESULTS

Of 462 patients, 26% had any Waddell signs and 10% had clinically significant Waddell signs. Nonemployed patients had a higher prevalence of Waddell signs than employed and retired patients (P = 0.0004 and P = 0.001, respectively). Subgroups of Medicaid participants as well as patients with secondary gain issues, including worker's compensation and motor vehicle accident, had a higher prevalence of 1+ Waddell signs than patients of other insurances (P < 0.0001 and P = 0.01, respectively). Medicaid participants had a higher prevalence of 3+ Waddell signs than other insurances (P = 0.002).

CONCLUSIONS

The presence of Waddell signs is associated with employment and insurance status. This suggests that social factors may affect patients' perceptions of their thoracic or low back pain. Clinicians aware of these factors can provide individualized care to their patients prone to poor outcomes.

Sex differences in interdisciplinary pain rehabilitation outcomes: a systematic review

OBJECTIVES

Interdisciplinary pain rehabilitation programs (IPRPs) are evidence-based treatments for chronic pain. Previous research has demonstrated that initial presentations of adult men and women admitted to IPRPs differ, but less is known about sex differences in IPRP treatment outcomes. To summarize and synthesize the current literature base on this topic, a systematic literature review was conducted that asked: are sex differences present in participant outcomes upon completion of interdisciplinary pain rehabilitation programs for cisgender patients? Four core domains of outcome measures were assessed: depression, pain catastrophizing, pain interference, and pain intensity/severity.

METHODS

Relevant studies meeting inclusion criteria were identified using a computer-aided search of the following electronic bibliographic databases: PubMed (MEDLINE), EMBASE, PsycINFO, CENTRAL (via Wiley Online Library), and CINAHL (via EBSCOhost). The reference list of relevant studies identified in the electronic searches was also screened to identify further studies.

RESULTS

This review concluded that most studies did not find any differences related to sex using the four outcome measures included in this review. This implies that specific considerations based on sex may not be needed when providing interdisciplinary pain rehabilitation.

CONCLUSIONS

Future research directions include comparison of additional outcome measures and exploring sex and gender issues in IPRP treatment in other formats than as a simple dichotomous variable.

A Cohort Study to Assess Cognitive Impairment and Its Effects on Older Patients in the Orthopedic Rehabilitation

Background

The cognitive role of older patients is regularly not investigated in orthopedic rehabilitation, after the elective as well as the nonelective operation. The objective of this research is to investigate the cognitive disorder and its influence over the duration of stay along with the functional consequences of the older patients who were admitted to orthopedic rehabilitation. Material and Methods. The inclusion criteria for this study were the patients with age above 50 years; who were admitted with the detection of orthopedic impairment and the surgery both elective and nonelective, investigated utilizing the MoCA (Montreal Cognitive Assessment) over admission, MBI (Modified Barthel Index), and FIM (Function Independent Measure) over admission and discharge status; and were discharged from the hospital. The demography, as well as the clinical data, comprising of the duration of stay, age and the detection was also reported.

Result

Of the 109 admitted patients, 80 patients were included in the study where n = 47 (58.75%) patients were females and n = 33 (41.25%) were males. The age group range was 50 to 94 years with a mean age of 78.5 years (SD = 8.27). The diagnostic groups included for the study were fractured neck of femur (n = 34; 42.5%), orthopedic surgery (n = 22; 27.5%), and other orthopedic surgery (n = 24; 30%). The mean duration of rehabilitation stay was reported as 34 (4.39), where the MoCA was reported as 22.17 (2.44); functional independence measures were as follows: motor admission as 53.97 (7.55), motor discharge as 76.27 (5.35), cognitive admission as 30.71 (1.99), and cognitive discharge as 31.85 (1.94). Here, the diagnosis was done over the fractured neck of the femur (i.e., NOF being 34 (42.5%), elective surgeries 22 (27.5%), and other orthopedic as 24 (30%)).

Conclusion

An excessive percentage of older-age patients in a rehabilitation unit with elective as well as nonelective diagnoses comprises the cognitive disorder. The cognitive screening was advised for all the older age patients in the rehabilitation units to report a specific rehabilitation plan to enhance the consequences along with the duration of stay. There is further study required to explore different cognitive strategies to enhance the rehabilitation consequences among older-age orthopedic patients.

Characteristics of patients who dropped out after multidisciplinary pain management in Japan: A prospective cohort study

BACKGROUND

Because regular visits to distant hospitals may be a burden to patients, both in terms of time and cost, some patients with chronic musculoskeletal pain may discontinue multidisciplinary pain treatment, unable to maintain motivation to attend.

OBJECTIVE

To evaluate and compare the pre-program characteristics of patients who dropped out and patients who continued treatment, thereby clarifying the characteristics of patients at risk of dropping out.

METHODS

A multidisciplinary pain management treatment program was implemented for patients at the Pain Management Center, Hoshi General Hospital. From April 2015 to March 2018, 23 patients participated in the program. Twelve of the 23 patients lived outside the prefecture where the hospital is located. Of these 12 patients, five completed the program, while seven did not. We compared the dropout and continuation groups in terms of patient characteristics, pain severity, pain-related psychosocial factors, and quality of life.

RESULTS

We found significant differences (p< 0.05) in median age, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire walking ability dysfunction score, and Roland-Morris Disability Questionnaire score.

CONCLUSIONS

The characteristics of patients who dropped out were older age, walking ability dysfunction, and low quality of life associated with low back pain.

Prior mood disorder diagnoses do not relate to current mood disorder symptoms or patient-reported disease severity in rotator cuff patients

BACKGROUND

Surgery for rotator cuff syndrome does not always produce symptom improvement. Biological factors may explain some symptoms, but mood disorder symptoms may also contribute. The purpose of this study is to examine the interaction between disease severity, prevalence of mood disorder diagnoses, and current mood disorder symptoms in preoperative rotator cuff patients.

METHODS

A prospective cohort of patients aged 35-75 years with unilateral rotator cuff disease awaiting surgery participated. Demographics, psychiatric history, the Hospital Anxiety & Depression Scale, and the Western Ontario Rotator Cuff index were collected. Descriptive and univariate statistical testing was performed.

RESULTS

Of 140 participants (75M:65W) aged 55 ± 8 years, 34 reported a prior diagnosis of a mood disorder. There was a moderate positive relationship between disease severity and current depression and anxiety scores. Women were more likely to carry a diagnosis of a mood disorder, but there were no differences in current symptom levels between genders. No differences were found in patient-reported outcome measure scores between patients with and without a mood disorder diagnosis.

DISCUSSION

Current mood disorder symptoms were associated with greater disease severity, whereas the presence of a past mood disorder diagnosis was not. Awareness of this relationship may reduce bias about past mood disorder diagnoses during decision-making.

What Influences Outcomes From Inpatient Multidisciplinary Pain Management Programs?: A Systematic Review and Meta-analysis

OBJECTIVES

Although inpatient multidisciplinary pain management programs (PMPs) are effective for chronic pain, not all patients benefit equally and there is limited evidence regarding predictors of outcome. This meta-analysis aimed to identify patient or program characteristics associated with outcomes from inpatient PMPs, and to examine the time course of effects following discharge.

MATERIALS AND METHODS

Medline, EBSCO, and Scopus were searched to identify articles reporting outcomes from inpatient multidisciplinary PMPs. Information was extracted on study design, participant and program characteristics, and outcomes. Effect sizes were computed for pain, physical function, depression, anxiety, and mental health outcomes. Study-level predictors of outcome were investigated with moderator analyses and meta-regression. A risk of bias assessment and sensitivity analyses were conducted and the GRADE criteria for prognostic studies were applied to assess confidence in findings.

RESULTS

In all, 85 studies (111 cohorts; 15,255 participants) were included. Three quarters of studies demonstrated low risk of bias. Larger effect sizes (for at least 1 outcome measure) occurred in studies where participants had more severe pain (greater intensity/longer duration), participants with alcohol or drug problems were not excluded, samples comprised mixed pain conditions, and programs included a cognitive component and/or a passive therapy component. Effect sizes for pain and physical function were maintained at follow-up, but effect sizes for depression and anxiety declined over time.

DISCUSSION

Inpatient multidisciplinary PMPs may be well suited to patients with severe or long-lasting pain. Programs should adopt broad patient inclusion criteria, and outcomes were similar for programs based on cognitive-behavioral versus mindfulness/acceptance-based therapies.

An Evaluation of Sex Differences in Patients With Chronic Pain Undergoing an Interdisciplinary Pain Treatment Program

OBJECTIVES

To determine if there are sex differences in a sample of patients participating in a 4-week interdisciplinary pain treatment program in (1) pretreatment pain intensity, physical function, psychological function, pain beliefs, kinesiophobia, pain catastrophizing, and activity management patterns; and (2) treatment response.

METHODS

Seventy-two men and 130 women with chronic pain completed study measures. Analyses of covariance (ANCOVAs) were performed to compare men and women on pretreatment measures. Repeated-measures ANCOVAs were used to compare both sexes on 3 treatment outcomes (pain intensity, physical function, and depressive symptoms).

RESULTS

Before treatment, compared to women, men reported higher levels of kinesiophobia, were more likely to view their pain as being harmful, and used more activity pacing when doing daily activities. Women were more likely to use an overdoing activity pattern than men. No sex differences emerged for pretreatment pain intensity, physical function, psychological function, catastrophizing, activity avoidance, or measures of other pain-related beliefs. At posttreatment, women reported more improvements in pain intensity and physical function compared to men, while both sexes reported similar reductions in depressive symptoms. All effect sizes for statistically significant findings were of small to moderate magnitude.

DISCUSSION

The results of this study suggest that men and women have a comparable profile with respect to the overall burden of chronic pain. Nevertheless, sex differences were found for certain pain beliefs and coping styles. Women appear to reap more benefits from the interdisciplinary pain management program than men. These findings indicate that further research to develop sex-specific assessment procedures and tailored pain treatments may be warranted.

Psychological and work-related outcomes after inpatient multidisciplinary rehabilitation of chronic low back pain: a prospective randomized controlled trial

Background

This study investigated the long-term effects (12 months post-rehabilitation) of a standard inpatient multidisciplinary rehabilitation program for patients with chronic low back pain (CLBP), in which a control group (CG) received pain competence training and an intervention group (IG) received combined pain competence and depression prevention training.

Methods

In this prospective control group study with cluster-block randomization, a total of n = 583 patients were included into per protocol analyses. To examine the effects of rehabilitation on depressive symptoms, pain self-efficacy, and work ability, patients were stratified in repeated-measures analyses of variance by treatment condition (IG vs. CG), level of depressive symptoms (low vs. high), and time of assessment (pre, post, 6, and 12 months after rehabilitation). The impact of each treatment on pain-related days of sick leave (DSL; dichotomized into ≤ vs. > 2 weeks) was determined separately by conducting non-parametric analyses. Multiple imputations (n = 1225) confirmed the results. Effects were interpreted if clinical significance was given.

Results

Only patients with high levels of depressive symptoms showed long-term improvements in depressive symptoms and self-efficacy. Long-term improvements in work ability index and mental work ability item were restricted to the IG. Furthermore, long-term effects on pain-related DSL were ascertained by per protocol and multiple imputation analyses only for the IG.

Conclusions

Patients with high levels of depressive symptoms showed improvements in depressive symptoms and self-efficacy, supporting the psychological effectiveness of both interventions. However, the beneficial long-term effects of rehabilitation on work ability and pain-related DSL among the IG support implementation of combined pain competence and depression prevention training.

Trial registration

DRKS00015465 (German Clinical Trial Register DRKS); date of registration: 03.09.2018.

Electronic supplementary material

The online version of this article (10.1186/s40359-019-0282-3) contains supplementary material, which is available to authorized users.

The presence of Waddell signs depends on age and gender, not diagnosis

Aims

The aim of this study was to determine if positive Waddell signs were related to patients’ demographics or to perception of their quality of life.

Patients and Methods

This prospective cross-sectional study included 479 adult patients with back pain from a university spine centre. Each completed SF-12 and Oswestry Disability Index (ODI) questionnaires and underwent standard spinal examinations to elicit Waddell signs. The relationship between Waddell signs and age, gender, ODI, Mental Component Score (MCS), and Physical Component Score (PCS) scores was determined.

Results

Of the 479 patients, 128 (27%) had at least one positive Waddell sign. There were significantly more women with two or more Waddell signs than men. The proportion of patients with at least one positive Waddell sign increased with age until 55 years, and then declined rapidly; none had a positive sign over the age of 75 years. Functional outcome scores were significantly worse in those with a single Waddell sign (p < 0.01). With one or more Waddell signs, patients’ PCS and ODI scores indicated a perception of severe disability; with three or more Waddell signs, patients’ MCS scores indicated severe disability. With five Waddell signs, ODI scores indicated that patients perceived themselves as crippled.

Conclusion

Positive Waddell signs, a potential indicator of central sensitization, indicated a likelihood of having functional limitations and an impaired quality of life, particularly in young women. Cite this article: Bone Joint J 2018;100-B:219–25.

Development and implementation of an inpatient multidisciplinary pain management program for patients with intractable chronic musculoskeletal pain in Japan: preliminary report

Introduction

Multidisciplinary pain management is a useful method to treat chronic musculoskeletal pain. Few facilities in Japan administer a multidisciplinary pain management program, especially an inpatient program. Therefore, we implemented a multidisciplinary pain management program in our hospital based on biopsychosocial factors guided by the recommendations of the International Association for the Study of Pain. The purpose of this study is to describe our inpatient pain management program for Japanese patients, which uses the biopsychosocial method of pain self-management.

Materials and methods

Fourteen patients with intractable chronic musculoskeletal pain, who were implemented a multidisciplinary pain management program in our hospital, were studied using the evaluation of the pain and associated factors and physical function.

Results

Significant improvement in outcomes were seen in the brief pain inventory, the pain catastrophizing scale (rumination, magnification, and helplessness), the pain disability assessment scale, the hospital anxiety and depression scale (anxiety and depression), the pain self-efficacy questionnaire, the EuroQol five dimensions questionnaire, and muscle endurance and physical fitness. We found no statistically significant differences in static flexibility or walking ability.

Conclusion

We developed an inpatient chronic pain management program for Japanese patients. Our results suggest that our program improves chronic musculoskeletal pain coping mechanisms, and that the program can improve patients' quality of life and some physical function. This inpatient pain management program is being expanded to better help intractable chronic musculoskeletal pain patients.

Lumbar magnetic resonance imaging findings in patients with and without Waddell Signs

BACKGROUND CONTEXT

Waddell Signs (WS), introduced as a method to establish patients with substantial psychosocial components to their low back pain, carry a negative association despite no literature evaluating whether physical disease is associated with them.

PURPOSE

To compare lumbar magnetic resonance imaging (MRI) findings between the patients with and without WS.

STUDY DESIGN

Retrospective cohort study based on prospectively collected data.

PATIENT SAMPLE

Thirty patients aged 35 to 55 years with an Oswestry Disability Index (ODI) score >50 randomly selected such that there was an even distribution of patients based on the number of WS.

OUTCOME MEASURES

ODI and Short Form-12 scores, number of WS, presence and severity of spinal pathology.

METHODS

MRIs were reviewed by three spine specialists blinded to clinical exam findings, number of WS, and patient identity. Type and severity of pathology and presence of surgical and non-surgical lesions were assessed, and findings were rank ordered based on the overall impression of the pathology. There was no external funding or potential conflicts of interest for this study.

RESULTS

There were significantly more individual pathologic findings in patients without WS (p=.02). However, there was no difference in the severity of pathology based on WS (p=.46). Furthermore, the rank ordering based on overall impression of severity showed no difference between the patients with and without WS (p=.20). Although 100% of the patients without WS showed pathologic findings on MRI, 70% of WS patients also had significant pathology on MRI. The prevalence of spondylolisthesis, stenosis, and disc herniation was similar (p=.41, p=.22, and p=.43, respectively). The prevalence and mean number of lesion amenable to surgery did not differ based on presence of WS (p=.21 and p=.18, respectively).

CONCLUSIONS

Patients with WS present a difficult diagnostic challenge for the physician as their organic symptoms are often coexistent with emotional fear avoidance behavior. Although there is more overall pathology in patients without WS, a significant number of these patients appear to have comparable spinal pathology with equivalent severity, which may be contributing to patients' symptoms and disability. Presence of these non-organic symptoms often makes us doubt these patients. However, as part of effective treatment, physicians should better understand both the physical and psychological components of patient disability.

Self-rated treatment outcomes in medical rehabilitation among German and non-German nationals residing in Germany: an exploratory cross-sectional study

Background

In many European countries, foreign nationals experience, on average, less favorable treatment outcomes in rehabilitative care than the respective majority population. In Germany, this for example is reflected in a lower occupational performance and a higher risk of disability retirement after rehabilitation as analyses of routine data show. However, little is known about the perspective of health care users. The aim of the present study was to compare self-rated treatment outcomes between German and non-German nationals undergoing in-patient medical rehabilitation in Germany.

Methods

We analyzed data from a cross-sectional representative rehabilitation patient survey of 239,811 patients from 642 clinics in Germany who completed about 3 weeks of in-patient rehabilitative treatment. The self-rating of the treatment outcome was based on a dichotomized Likert scale consisting of three items. A multilevel logistic regression analysis adjusted for various demographic, socio-economic, health and other covariates was conducted to examine differences in the self-rated treatment outcome between German and non-German nationals.

Results

Of the 239,811 respondents 0.9 % were nationals from Turkey, 0.8 % had a nationality from a former Yugoslavian country, 0.9 % held a nationality from the South European countries Portugal, Spain, Italy or Greece and 1.9 % were nationals from other countries. Non-German nationals reported a less favorable self-rated outcome than Germans. Adjusted odds ratios [OR] for reporting a less favorable treatment outcome were 1.24 (95 %-confidence interval [95 %-CI]: 1.12–1.37) for nationals from the South European countries Portugal/Spain/Italy/Greece, 1.62 (95 %-CI: 1.45–1.80) for Turkish nationals and 1.68 (95 %-CI: 1.52–1.85) for nationals from Former Yugoslavia.

Conclusions

Knowledge on health outcomes from the patients’ point of view is important for the provision of patient-centered health care. Our study showed that non-German nationals report less favorable outcomes of rehabilitative care than Germans. This may be due to cultural and religious needs not sufficiently addressed by health care providers. In order to improve rehabilitative care for non-German nationals, rehabilitative services must become sensitive to the needs of this population group. Diversity management can contribute to this process.

The effect of intraoperative sounds of saw and hammer on psychological condition in patients with total knee arthroplasty: prospective randomized study

Purpose. Surgical procedures are likely to be stressful for patients and their families. Total knee arthroplasty (TKA) is a major surgical procedure used in the treatment of osteoarthritis. During this procedure the sounds of the saw and hammer may irritate the patient and adversely affect mood. The present study examines the effect of these intraoperative sounds during TKA on postoperative mood and anxiety, by comparing two different anesthetic procedures. Methods. A total of 40 patients who underwent TKA for grade IV gonarthrosis participated in the study. Patients were randomly divided into two groups: 20 patients in the general anesthesia group and 20 patients in the spinal anesthesia group. Mood and anxiety changes were evaluated using the Profile of Mood States (POMS) and State-Trait Anxiety Inventory (STAI) instruments, respectively. Results. The postoperative POMS value in the spinal anesthesia group was definitively higher than the general anesthesia group, though the difference in preoperative and postoperative POMS and STAI scores between the two groups was not significant. Conclusion. It would seem that sounds of hammer and saw have no evident negative effect on patient's mood. Regional anesthesia is advisable for TKA patients and appropriate sedation can be administered during the operation if needed.

Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain

PURPOSE

The present study aimed to identify predictors of rehabilitation outcome for patients with chronic musculoskeletal pain (CMP) and psychological problems.

METHODS

A retrospective cohort study including 230 adult patients with CMP admitted for multidisciplinary pain rehabilitation. Potential predictors were patient characteristics, duration of complaints, baseline functioning, pain, personality, coping style, fear of movement, psychological distress and type of treatment. Outcome measures were physical functioning, mental health, pain and patient-reported effect. Multiple (logistic) regression models were used to identify predictors.

RESULTS

Patients who were more disabled and patients with more pain benefitted more from the rehabilitation treatment than less disabled patients or those with less pain. Age, work status, vitality, depression and coping style also predicted outcomes significantly. The models explained between 27 and 80% of the outcomes. There was an interaction between type of treatment, work status and the baseline pain score as regards the outcome in terms of pain.

CONCLUSIONS

No strong predictors of treatment outcome were found other than the baseline scores of the respective outcome variables. More disabled patients and patients with more pain benefitted more from the rehabilitation program. Other predictors improved the prediction models slightly. Implications for Rehabilitation It remains challenging to correctly predict the outcome of treatment from patients' baseline sociodemographic and psychological characteristics; predictors other than baseline scores of the outcome variables are only slightly associated with treatment outcome. Patients with chronic musculoskeletal pain and poor physical functioning or mental health benefit most from pain rehabilitation. Older patients benefit less from a pain rehabilitation program than younger patients in terms of physical functioning. Pain reduction during a pain rehabilitation program is greatest in patients with high pain intensity who are not at work at the start of the rehabilitation program. Coping style influences the outcome of rehabilitation of patients with chronic musculoskeletal pain.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Depression impacts the course of recovery in patients with acute low-back pain

Little is known about the course of recovery of acute low back pain (LBP) patients as a function of depression. In a prospective study, 286 acute LBP patients were assessed at baseline and followed up over 6 months. Recovery was defined as improvement in the Oswestry Disability Index (ODI). Repeated-measures analysis of covariance was employed with ODI as repeated factor, age, sex, and body mass index as covariates, depression and all other potential prognostic factors as between-subject factors. Of study participants, 18% were classified as depressive (>33 points on the Zung Self-Rating Depression Scale). Of 286 participants, 135 were lost to follow-up. In the longitudinal sample of 151 patients the course of recovery was slower in depressive patients. Depression was associated with LBP especially after 6 weeks and should therefore be included in screening instruments for acute LBP patients to identify those at risk of delayed recovery at an early stage.

Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychological programme for chronic low back pain

PURPOSE

The aim of this longitudinal study is to determine the factors which predict a successful 1-year outcome from an intensive combined physical and psychological (CPP) programme in chronic low back pain (CLBP) patients.

METHODS

A prospective cohort of 524 selected consecutive CLBP patients was followed. Potential predictive factors included demographic characteristics, disability, pain and cognitive behavioural factors as measured at pre-treatment assessment. The primary outcome measure was the oswestry disability index (ODI). A successful 1-year follow-up outcome was defined as a functional status equivalent to 'normal' and healthy populations (ODI ≤22). The 2-week residential programme fulfills the recommendations in international guidelines. For statistical analysis we divided the database into two equal samples. A random sample was used to develop a prediction model with multivariate logistic regression. The remaining cases were used to validate this model.

RESULTS

The final predictive model suggested being 'in employment' at pre-treatment [OR 3.61 (95 % CI 1.80-7.26)] and an initial 'disability score' [OR 0.94 (95 % CI 0.92-0.97)] as significant predictive factors for a successful 1-year outcome (R (2) = 22 %; 67 % correctly classified). There was no predictive value from measures of psychological distress.

CONCLUSION

CLBP patients who are in work and mild to moderately disabled at the start of a CPP programme are most likely to benefit from it and to have a successful treatment outcome. In these patients, the disability score falls to values seen in healthy populations. This small set of factors is easily identified, allowing selection for programme entry and triage to alternative treatment regimes.

Direct and indirect costs in persons with chronic back pain and comorbid mental disorders--a systematic review

OBJECTIVE

Direct inpatient and outpatient healthcare costs as well as indirect costs (e.g. productivity losses) are hypothesized to be increased in chronic back pain (CBP) patients with mental disorders. The aim of this systematic review is to examine this hypothesis by comparing costs in CBP patients with and without mental disorders.

METHODS

A comprehensive literature search (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS) was conducted. All studies were included which allowed for a comparison of direct and indirect costs between CBP patients with and without mental disorders.

RESULTS

Of 2283 potentially relevant articles, 10 studies fulfilled the inclusion criteria. Total healthcare costs (SMD=0.16 [SE=0.06]; n=1), CBP-related healthcare costs (SMD=0.21 [0.06]; n=1), CBP-related primary care visits (OR=1.6 [95%-CI:1.2-2.3]; n=1), CBP-related specialty care visits (OR=1.4 [1.0-2.0];n=1), CBP-related radiologic procedures (OR=1.6 [1.0-2.5]; n=1) and mental health visits (OR=8.1 [7.3-9.1]; n=2) were increased in CBP patients with depression. The incidence of new surgeries was increased in CBP patients with PTSD (OR=4.2 [1.6-10.8]; n=1). Pain-related healthcare use (n=1) in CBP patients with both depression and anxiety and CBP-related hospital admissions (n=1) in CBP patients with depression were not increased. Regarding indirect costs results were inconsistent for both return to work rates (n=3) and work absence (n=2).

CONCLUSION

The results indicate increased direct but not indirect costs in CBP patients with mental disorders. However, the evidence is limited due to the low number of studies per outcome. This is all the more problematic, since the adequate allocation of healthcare resources will become a major topic of health care policy due to limited resources.

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.

Long-term effects of a cognitive-behavioral training program for the management of depressive symptoms among patients in orthopedic inpatient rehabilitation of chronic low back pain: a 2-year follow-up

The aim of the present study was to investigate the 2-year outcome of a cognitive-behavioral training program for the management of depressive symptoms for patients with chronic low back pain (CLBP) and co-existing depressive symptoms compared with the standard rehabilitation. Therefore, a quasi-experimental 3 × 2 × 5 (treatment condition × gender × time) repeated measures design with five assessment points (pre-treatment, post-treatment, 6-, 12-, and 24-month follow-up) was employed among N = 153 patients with CLBP, aged 33-62 years. Patients were consecutively assigned to one of three treatment conditions: patients with no or mild depressive symptoms were treated with the standard rehabilitation (CG) and patients with moderate or severe depressive symptoms were either treated with the standard rehabilitation (CG(depr)) or the standard rehabilitation plus cognitive-behavioral management of depressive symptoms (IG(depr)). Patients in the IG(depr) significantly improved in mental health up to the 6-month follow-up and in anxiety and depressive symptoms up to the 24-month follow-up. Only short- or mid-term improvements were found in the CG(depr). In conclusion, the new cognitive-behavioral training program augmented the long-term rehabilitation success in this highly strained subgroup of patients with CLBP and depressive symptoms.