Do psychological factors increase the risk for back pain in the general population in both a cross-sectional and prospective analysis?

Low back pain among college students in a public Saudi university: A cross-sectional study

Background

Low back pain (LBP) is the most prevalent orthopedic condition worldwide. University students are more likely to have this issue due to their demanding and time-consuming course load. This study aimed to investigate the prevalence of LBP and the factors that lead to it among students at the Imam Mohammad Ibn Saud Islamic University (IMSIU).

Methods

This cross-sectional study targeted undergraduate students using an online self-administered questionnaire. A descriptive analysis method was conducted.

Results

Of the 830 students who completed the survey, 71.4% were females. About two-thirds were aged between 18 and 22 years. Our study shows that 68.2% had complained of recent LBP. The most significant prevalent factor associated with LBP among IMAMU students, 94.2%, was prolonged sitting. Heavy object lifting is 93.2%, and unhealthy seating/body position is 90.2%, which comes in second and third place. Those who complained about the discomfort of their lecture hall seats were shown to be dramatically more likely (5.549 times more) to develop LBP than students who did not. Students with a positive history of depression were significantly more prone (2.565-fold) to LBP. A positive family history of LBP and smoking cigarettes were found to increase the chance of developing LBP.

Conclusion

LBP among IMSIU students is high, mainly because of prolonged sitting, heavy object lifting, and unhealthy sitting and/or body position. There is a strong association between LBP and a positive family history of LBP, smoking, and uncomfortable seats. Prevenive measures, such as an intervention program for university students, are required.

Biobehavioral Predictors of Pain Intensity, Pain Interference, and Chronic Pain Episodes: A Prospective Cohort Study of African-American Adults

Racial disparities in pain experiences are well-established, with African-American (AA) adults reporting higher rates of daily pain, increased pain severity, and greater pain-related interference compared to non-Hispanic Whites. However, the biobehavioral factors that predict the transition to chronic pain among AA adults are not well understood. This prospective cohort study provided a unique opportunity to evaluate predictors of chronic pain onset among 130 AA adults (81 women), ages 18 to 44, who did not report chronic pain at their baseline assessment and subsequently completed follow-up assessments at 6- and 12-months. Outcome measures included pain intensity, pain-related interference, and chronic pain status. Comprehensive assessments of sociodemographic and biobehavioral factors were used to evaluate demographics, socioeconomic status, stress exposure, psychosocial factors, prolonged hypothalamic-pituitary-adrenal secretion, and quantitative sensory testing responses. At baseline, 30 adults (23.1%) reported a history of prior chronic pain. Over the 12-month follow-up period, 13 adults (10.0%) developed a new chronic pain episode, and 18 adults (13.8%) developed a recurrent chronic pain episode. Whereas socioeconomic status measures (ie, annual income, education) predicted changes in pain intensity over the follow-up period, quantitative sensory testing measures (ie, pain threshold, temporal summation of pain) predicted changes in pain interference. A history of chronic pain and higher depressive symptoms at baseline independently predicted the onset of a new chronic pain episode. The present findings highlight distinct subsets of biobehavioral factors that are differentially associated with trajectories of pain intensity, pain-related interference, and onset of chronic pain episodes in AA adults. PERSPECTIVE: This prospective study sought to advance understanding of biobehavioral factors that predicted pain outcomes over a 12-month follow-up period among AA adults without chronic pain at their initial assessment. Findings revealed distinct subsets of factors that were differentially associated with pain intensity, pain-related interference, and onset of chronic pain episodes.

Identifying Clinical Phenotypes in People Who Are Hispanic/Latino With Chronic Low Back Pain: Use of Sensor-Based Measures of Posture and Movement, Pain, and Psychological Factors

OBJECTIVE

The aim of this study was to identify clinical phenotypes using sensor-based measures of posture and movement, pain behavior, and psychological factors in Hispanic/Latino people with chronic low back pain (CLBP).

METHODS

Baseline measures from an ongoing clinical trial were analyzed for 81 Hispanic/Latino people with CLBP. Low back posture and movement were measured using commercial sensors during in-person testing and 8 hours of ecological monitoring. Magnitude, frequency, and duration of lumbar movements, sitting and standing postures were measured. Movement-evoked pain was assessed during in-person movement testing. Psychological measures included the Pain Catastrophizing Scale and the Fear Avoidance Beliefs Questionnaire. Random forest analysis was conducted to generate 2 groups and identify important variables that distinguish groups. Group differences in demographics, pain, psychological, and posture and movement variables were examined using t-tests and chi-square analyses.

RESULTS

Two subgroups of Hispanic/Latino people with CLBP were identified with minimal error (7.4% misclassification ["out-of-bag" error]). Ecological posture and movement measures best distinguished groups, although most movement-evoked pain and psychological measures did not. Group 1 had greater height and weight, lower movement frequency, more time in sitting, and less time in standing. Group 2 had a greater proportion of women than men, longer low back pain duration, higher movement frequency, more time in standing, and less time in sitting.

CONCLUSION

Two distinct clinical phenotypes of Hispanic/Latino people with CLBP were identified. One group was distinguished by greater height and weight and more sedentary posture and movement behavior; the second group had more women, longer duration of low back pain, higher lumbar spine movement frequency, and longer duration of standing postures.

IMPACT

Ecological measures of posture and movement are important for identifying 2 clinical phenotypes in Hispanic/Latino people with CLBP and may provide a basis for a more personalized plan of care.

LAY SUMMARY

Wearable sensors were used to measure low back posture and movement in Hispanic/Latino people with chronic low back pain. These posture and movement measures helped to identify 2 different clinical subgroups that will give physical therapists more information to better personalize treatment for chronic low back pain in Hispanic/Latino patients.

Cross-cultural translation, validity, and reliability of the Turkish version of the Back Pain Attitudes Questionnaire

BACKGROUND

As the Back Pain Attitudes Questionnaire (Back-PAQ), a validated instrument, could be performed to evaluate biopsychosocial dimensions of back pain, it has not been translated and adapted for Turkish population.

OBJECTIVES

It was aimed to translate and cross-culturally adapt the Back-PAQ (versions of 34-item, 20-item, and 10-item) into Turkish language and analyse the validity and reliability of the Back-PAQ-Turkish version (Back-PAQ-Tr).

STUDY DESIGN

Study of diagnostic accuracy/assessment scale.

METHODS

The translation and cross-cultural adaptation process were carried out in several steps according to international best-practice guidelines. 173 participants with back pain were recruited. Turkish version of the Tampa Scale of Kinesiophobia (TSK-Tr) and Fear Avoidance Beliefs Questionnaire (FABQ-Tr) were used to investigate the convergent validity.

RESULTS

Internal consistency of the Back-PAQ-Tr, Back-PAQ-Tr-20, and Back-PAQ-Tr-10 were 0.82, 0.78 and 0.68, respectively. Test-retest reliability was excellent for Back-PAQ-Tr (ICC = 0.95) and Back-PAQ-Tr-20 (ICC = 0.95), but weak for Back-PAQ-Tr-10 (ICC = 0.50). A weak correlation was found between all versions of Back-PAQ-Tr and TSK-Tr & FABQ-Tr, except for the moderate correlation between Back-PAQ-Tr-10 and TSK-Tr (r = -0.51) & the physical activity score of FABQ-Tr (r = -0.51). Back-PAQ-Tr, Back-PAQ-Tr-20, and Back-PAQ-Tr-10 accounted for 66.2%, 60.5%, and 78.2% of the variance in the data set, respectively.

CONCLUSION

The versions of 34-item and 20-item Back-PAQ-Tr are reliable and valid questionnaire to assess Turkish populations' attitudes and beliefs regarding back pain. Since the reliability of the 10-item version was determined to be quite low, we particularly recommend the use of the versions of Back-PAQ-Tr and Back-PAQ-Tr-20.

Effect of selected group of asana when used as an adjunct in management of cervical spondylosis of mild to moderate severity: An observational study

BACKGROUND

"Cervical spondylosis" (CS) is a collective term used for non-specific neck pain post 30 age group. Management of CS is mainly non-surgical, particularly in mild to moderate severity that includes the oral anti-inflammatory drugs, exercises, manipulation, mobilization, or combination of these.

OBJECTIVE

The objective of the study is to assess the possible benefit of a selected group of asana in a group of patients over a short time frame and assess their functional outcome.

MATERIALS AND METHODS

An observational study of cohort of patients having mild to moderate CS, who visited the AYUSH department between May 2016 and November 2016 were included. "Selected group of Asana (SGOA)" was practiced for 30 min supervised and then home-based for a period of 8 weeks with usual standard treatment. Patients followed up fortnightly, and their degree of severity & disability assessed.

RESULTS

Thirty patients with 19 males and 11 females having ages mean ± SD 45.61 ± 8.3 and 44.18 ± 9.78 having NDI score of mean ± SD 17.83 ± 4.749 at baseline (0 weeks) were included. Patients showed an improvement in NDI score to finally 7.40 ± 3.180, p-value = 0.0001. This improvement was also noted at various time intervals (p-value = 0.0001 each time), as seen in the post hoc analysis.

CONCLUSION

Yogic practices "Specific Group of Asana" done for eight weeks on a home-based program could be useful in reducing pain and disability in people suffering from CS of mild to a moderate degree. However, more extensive, comparative, and multi-centric trials are required for establishing this as a treatment modality.

Rasch analysis of the Back Pain Attitudes Questionnaire (Back-PAQ)

CONTEXT

As psychosocial factors have been recognised as significant predictors of the recovery trajectory from chronic back pain, the 34-item Back Pain Attitudes Questionnaire (Back-PAQ) was developed based on themes obtained from patient interviews, but previous psychometric analyses with a general population sample revealed uncertainty around the factor structure of the instrument.

OBJECTIVES

To provide more detailed information about the psychometric properties of the Back-PAQ when used with participants from the general population and also to test the internal validity of the tool for use with General Practitioners (GPs).

METHODS

After applying partial-credit Rasch analysis with a sample of participants from the general population (n = 600), a replication analysis was conducted with a sample of GPs (n = 184). This approach permitted examination of sample-specific personal factors for differential item functioning. Subtests were used to differentiate between local dependency due to underlying dimensionality from local dependency due to method effects.

RESULTS

A unidimensional fit to the Rasch model was achieved after 14 misfitting items had been deleted. The final 20-item solution also fit with a sample of 184 GPs. In both cases, the Back-PAQ-20 demonstrated good reliability (PSI ≥ 0.80), with no evidence of differential item functioning by personal factors.

CONCLUSION

The ordinal-to-interval conversion algorithms presented here further enhance the precision of the scale and permit analysis of Back-PAQ-20 scores using parametric statistics. The present study provided evidence for valid and reliable assessment of the back pain recovery beliefs of both users as well as providers of health services.IMPLICATIONS FOR REHABILITATIONPsychosocial factors have been recognised as significant predictors of the recovery trajectory from chronic back pain.The 34-item Back Pain Attitudes Questionnaire (Back-PAQ) was developed based on themes obtained from patient interviews, but previous psychometric analyses with a general population sample revealed uncertainty around the factor structure of the instrument.The 20-item version of the Back Pain Attitudes Questionnaire (Back-PAQ) is shown here to have strong psychometric properties for administration with users and providers of health services.

Introduction of a psychologically informed educational intervention for pre-licensure physical therapists in a classroom setting

BACKGROUND

There is an increasing need for physical therapists to address psychosocial aspects of musculoskeletal pain. Psychologically informed practice is one way to deliver this type of care through the integration of biopsychosocial interventions into patient management. An important component of psychologically informed practice is patient centered communication. However, there is little research on how to effectively implement patient centered communication into pre-licensure training for physical therapists.

METHODS

Thirty Doctor of Physical Therapy (DPT) students took part in an educational intervention that consisted of one 4-h didactic teaching session and three 1-h experiential learning sessions. Prior to the first session, students performed an examination of a standardized patient with chronic low back pain and were assessed on psychologically informed physical therapy (PIPT) adherent behaviors via a rating scale. Students also completed the Pain Attitudes and Beliefs Scale (PABS-PT). After the last experiential session, students evaluated another standardized patient and were reassessed on PIPT adherent behaviors. Students retook the PABS-PT and qualitative data was also collected.

RESULTS

After the educational intervention, students had positive changes in their pain attitudes and belief scores indicating a stronger orientation toward a psychosocial approach to patient care (p < 0.05). Additionally, after the intervention, students showed improvements in their adherence to using PIPT behaviors in their simulated patient interactions (p < 0.05). Qualitatively, students reported a high acceptability of the educational intervention with common themes indicating improved confidence with treating and communicating with complex patients.

CONCLUSION

Students had attitudes and beliefs shift towards a more psychosocial orientation and demonstrated improved PIPT behaviors in simulated patient interactions after a brief educational intervention. Future research should investigate best practices for implementation of psychologically informed physical therapy for licensed clinicians.

Preoperative patient expectations and pain improvement after adult spinal deformity surgery

OBJECTIVE

Patients' expectations for pain relief are associated with patient-reported outcomes after treatment, although this has not been examined in patients with adult spinal deformity (ASD). The aim of this study was to identify associations between patients' preoperative expectations for pain relief after ASD surgery and patient-reported pain at the 2-year follow-up.

METHODS

The authors analyzed surgically treated ASD patients at a single institution who completed a survey question about expectations for back pain relief. Five ordinal answer choices to "I expect my back pain to improve" were used to categorize patients as having low or high expectations. Back pain was measured using the 10-point numeric rating scale (NRS) and Scoliosis Research Society-22r (SRS-22r) patient survey. Preoperative and postoperative pain were compared using analysis of covariance.

RESULTS

Of 140 ASD patients eligible for 2-year follow-up, 105 patients (77 women) had pre- and postoperative data on patient expectations, 85 of whom had high expectations. The mean patient age was 59 ± 12 years, and 46 patients (44%) had undergone previous spine surgery. The high-expectations and low-expectations groups had similar baseline demographic and clinical characteristics (p > 0.05), except for lower SRS-22r mental health scores in those with low expectations. After controlling for baseline characteristics and mental health, the mean postoperative NRS score was significantly better (lower) in the high-expectations group (3.5 ± 3.5) than in the low-expectations group (5.4 ± 3.7) (p = 0.049). The mean postoperative SRS-22r pain score was significantly better (higher) in the high-expectations group (3.3 ± 1.1) than in the low-expectations group (2.6 ± 0.94) (p = 0.019).

CONCLUSIONS

Despite similar baseline characteristics, patients with high preoperative expectations for back pain relief reported less pain 2 years after ASD surgery than patients with low preoperative expectations.

Efficacy and mechanisms of a single-session behavioral medicine class among patients with chronic pain taking prescription opioids: study protocol for a randomized controlled trial

Background

Independent of pain intensity, pain-specific distress is highly predictive of pain treatment needs, including the need for prescription opioids. Given the inherently distressing nature of chronic pain, there is a need to equip individuals with pain education and self-regulatory skills that are shown to improve adaptation and improve their response to medical treatments. Brief, targeted behavioral medicine interventions may efficiently address the key individual factors, improve self-regulation in the context of pain, and reduce the need for opioid therapy. This highlights the critical need for targeted, cost-effective interventions that efficiently address the key psychological factors that can amplify the need for opioids and increased risk for misuse. In this trial, the primary goal is to test the comparative efficacy of a single-session skills-based pain management class to a health education active control group among patients with chronic pain who are taking opioids.

Methods/design

Our study is a randomized, double-blind clinical trial testing the superiority of our 2-h, single-session skills-based pain management class against a 2-h health education class. We will enroll 136 adult patients with mixed-etiology chronic pain who are taking opioid prescription medication and randomize 1:1 to one of the two treatment arms. We hypothesize superiority for the skills-based pain class for pain control, self-regulation of pain-specific distress, and reduced opioid use measured by daily morphine equivalent. Team researchers masked to treatment assignment will assess outcomes up to 12 months post treatment.

Discussion

This study aims to test the utility of a single-session, 2-h skills-based pain management class to improve self-regulation of pain and reduce opioid use. Findings from our project have the potential to shift current research and clinical paradigms by testing a brief and scalable intervention that could reduce the need for opioids and prevent misuse effectively, efficiently, and economically. Further, elucidation of the mechanisms of opioid use can facilitate refinement of more targeted future treatments.

Trial registration

ClinicalTrials.gov, ID: NCT03950791. Registered on 10 May 2019.

The Impact of Cognitive Anxiety and the Rating of Pain on Care Processes in a Vigilance Task: The Important Part Played by Age

Chronic pain is a serious public health problem that has grown exponentially in recent years, which is why it has received the attention of numerous researchers. Most of the studies in the field of chronic pain have focused on care as a mediating variable on the perception of painful stimuli and emotions. Nevertheless, there are very few studies that have gone in the opposite direction. This study's aim is therefore to analyse the impact of emotional variables (anxiety and depression), the rating of pain, and age on vigilance processes in a sample of patients with chronic pain. To do so, the attentional performance of a cohort of 52 patients with chronic pain was measured through the use of a modified dot-probe task. Furthermore, all the participants were evaluated using the following self-report measures: Beck's Depression Inventory-II (BDI-II), the McGill Pain Questionnaire, and the Pain Anxiety Symptoms Scale-20 (PASS-20). Stepwise multiple linear regression analysis revealed a significant negative correlation between the pain rating index and the number of mistakes the participants made during the attention test. There was also a positive and significant correlation with age and another negative and significant correlation with cognitive anxiety regarding the overall performance times during the undertaking of the experimental task. These results point to the importance of a more in-depth understanding of the impact that the emotional variables and other variables such as age have on attentional processes and the rating of pain. Finally, the discussion focuses on the implications these results could have for clinical practice or for future research studies in this field.

Back pain and depressive symptoms: A systematic review and meta-analysis

BACKGROUND

Low back pain is a common disorder that has many consequences. This study is an attempt to meta-analyze the risk of depression symptoms in back pain.

METHOD

Four databases were selected for review, and this search was conducted using key words. Eleven eligible articles were selected for review and meta-analysis was conducted. Subgroup analyses were continued with study design and the method of measuring depression. Also, the heterogeneity and publication bias were examined.

RESULTS

Eleven cohort and cross-sectional articles are used in the meta-analysis between back pain and depressive symptoms. The odds ratio 2.07 was calculated for this relationship. In prospective-cohort studies, 1.71 (95% confidence interval = 1.24-2.36) results indicated that back pain is a risk factor for depression symptoms and in cross-sectional studies, pooled odds ratio (2.33; 95% confidence interval = 1.29-4.21) showed that back pain is associated with depression symptoms. Some degree of publication bias was not found in the study.

CONCLUSIONS

Back pain is an effective factor in increasing the likelihood of depression. Adoption of effective prevention and treatment approaches can play an important role in reducing the psychological consequences in these individuals.

Effects of Biopsychosocial Education on the Clinical Judgments of Medical Students and GP Trainees Regarding Future Risk of Disability in Chronic Lower Back Pain: A Randomized Control Trial

Background

Chronic lower back pain (CLBP) is a major health care burden and often results in workplace absenteeism. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions informed by the flags approach, which integrates cognitive and behavioral approaches via identification of biopsychosocial barriers to recovery, have resulted in reduced pain-related work absences and increased return to work for individuals with CLBP. However, research indicates that physicians’ adherence to biopsychosocial guidelines is low.

Objective

The current study examined the effects of a flags approach–based educational intervention on clinical judgments of medical students and general practitioner (GP) trainees regarding the risk of future disability of CLBP patients.

Design

Randomized controlled trial (trial registration number: ISRCTN53670726).

Setting

University classroom.

Subjects

Medical students and GP trainees.

Methods

Using 40 fictional CLBP cases, differences in clinical judgment accuracy, weighting, and speed (experimental N = 32) were examined pre- and postintervention, as were flags approach knowledge, pain attitudes and beliefs, and empathy, in comparison with a no-intervention control group (control N = 31).

Results

Results revealed positive effects of the educational intervention on flags approach knowledge, pain-related attitudes and beliefs, and judgment weighting of psychologically based cues; results are discussed in light of existing theory and research.

Conclusions

Short flags approach–based educational video interventions on clinical judgment-making regarding the risk of future disability of CLBP patients may provide opportunities to gain biopsychosocial knowledge, overcome associated attitude barriers, and facilitate development of clinical judgment-making more aligned with psychological cues.

The relationship between catastrophizing and altered pain sensitivity in patients with chronic low-back pain

Changes in central pain processing have been shown in patients with chronic low-back pain (cLBP). We used quantitative sensory testing methods to identify differences in pain sensitization between patients with cLBP (N = 167) and healthy controls (N = 33). Results indicated that, compared with healthy pain-free controls, cLBP patients showed increased sensitivity and greater painful aftersensations for mechanical pressure and pin-prick stimuli and lower tactile spatial acuity in the 2-point discrimination task (ps < 0.05). Then, we examined the role of pain catastrophizing as a mediator of the group differences in pain sensitization. We found that catastrophizing partially accounted for group differences in pressure required to produce moderate pain. Finally, we examined the relationship between pain sensitization, catastrophizing, and clinical pain among patients with cLBP. We found that catastrophizing and deep-tissue pressure pain were associated with greater pain intensity in the past month, week, and at the visit as well as low-back pain bothersomeness. Furthermore, deep-tissue pressure pain mediated the associations between catastrophizing and both pain in the past month and low-back pain severity. Taken together, these results indicate that not only do patients with cLBP demonstrate increased pain sensitization and decreased sensitivity to innocuous stimuli, but these changes are also linked with increased catastrophizing. Furthermore, both catastrophizing and sensitization are associated with increased clinical pain among cLBP patients.

Testing a Model of Consultation-based Reassurance and Back Pain Outcomes With Psychological Risk as Moderator: A Prospective Cohort Study

OBJECTIVES

Reassurance is an essential part of treatment for low back pain (LBP), but evidence on effective methods to deliver reassurance remains scarce. The interaction between consultation-based reassurance and patients' psychological risk is unknown. Our objective was to investigate the relationship between consultation-based reassurance and clinical outcomes at follow-up, in people with and without psychological risk.

METHODS

We tested the associations between specific reassurance components (data gathering, relationship building, generic reassurance, and cognitive reassurance), patients' psychological risk (the presence of depression, anxiety, catastrophizing, or fear-avoidance), and postconsultation outcomes including, satisfaction and enablement, disability, pain, and mood at 3-month follow-up.

RESULTS

Adjusted linear regression models using data from patients who had recently consulted for LBP in primary care (n=142 in 43 practices) indicated that all reassurance components were strongly associated with increased satisfaction, whereas generic reassurance was significantly associated with postconsultation enablement. Generic reassurance was also associated with lower pain at 3 months, whereas cognitive reassurance was associated with increased pain. A significant interaction was observed between generic reassurance and psychological risk for depression at 3 months: high rates of generic reassurance were associated with lower depression in low-risk patients, but with higher rates of depression for high-risk groups.

DISCUSSION

The findings support the hypothesis that different components of reassurance are associated with specific outcomes, and that psychological risk moderates this relationship for depression. Clinicians reassuring behaviors might therefore have the potential to improve outcomes in people with LBP, especially for patients with higher psychological risk profiles.

Depression is Closely Associated With Chronic Low Back Pain in Patients Over 50 Years of Age: A Cross-sectional Study Using the Sixth Korea National Health and Nutrition Examination Survey (KNHANES VI-2)

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

This study was designed to analyze the relationship between the presence and severity of depression and low back pain (LBP) in a representative sample of the general population using a self-report screening questionnaire for depression.

SUMMARY OF BACKGROUND DATA

There is increasing evidence supporting an association between depression and LBP. However, the degree of the association between these two conditions in the general population is poorly understood.

METHODS

Health surveys and examinations were conducted on a nationally representative sample (n = 7550) of Koreans. LBP status was determined by a simple survey response concerning LBP >30 days during the past 3 months. Depression was defined as individuals with a total score >10 on the Patient Health Questionnaire (PHQ)-9 survey. The severity of depression was categorized as none (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27) according to PHQ-9 score. Data regarding demographics, socioeconomic history, and comorbid health conditions were used to analyze adjusted, weighted logistic regression models.

RESULTS

In the Korean population, the prevalence of depression was significantly greater in individuals with LBP (20.3%) than in those without LBP (4.5%). On multivariate logistic regression analysis, the presence of depression was significantly associated with LBP (adjusted odd ratio [aOR]: 3.93, P < 0.001). The risk of LBP increased with increasing severity of depression as follows: severe depression (aOR: 9.28, P < 0.001), moderately severe depression (aOR: 3.24, P = 0.001), moderate depression (aOR: 4.97, P < 0.001), and mild depression (aOR: 2.48, P < 0.001).

CONCLUSION

Depression is more common in patients with LBP among Koreans. The presence of depression was significantly associated with LBP, especially in severely depressed individuals.

LEVEL OF EVIDENCE

3.

Spirituality in pain medicine: A randomized experiment of pain perception, heart rate and religious spiritual well-being by using a single session meditation methodology

The aim of this study is to investigate different effects on pain perception among randomly assigned volunteers practicing meditation compared to a relaxation condition. The study examines whether participants of the experimental conditions (meditation versus relaxation) differ in the change of pain perception and heart rate measurement and in religious and spiritual well-being after an intervention. Method: 147 volunteers (long-term practitioners and novices) were randomly assigned to the experimental conditions with a headphone guided 20-minute single session intervention. The change in their pre- and post-intervention pain perception was measured using Quantitative Sensory Testing and Cold Pressor Testing (CPTest), their stress-level was compared by monitoring heart rate, and their religious and spiritual well-being by using the Multidimensional Inventory for Religious/Spiritual Well-Being (MI-RSB48). Additionally, dimensions of the Brief Symptom Inventory (BSI) measured the psychological resilience of the participants; pain and stress experience, and the state of relaxation and spirituality experience were assessed. Five persons were excluded due to failure in measuring the heart rate and 29 participants had to be excluded because of high values on the BSI. Results: The meditation group showed an increase in their pain tolerance on the CPTest and a decrease in their pain intensity for heat after the experimental condition, in contrast to the relaxation group. Futhermore, the meditation group showed a higher level of religious spiritual well-being (MI-RSB48 Total score) as well as in the sub-dimensions General Religiosity, Forgiveness, and Connectedness after the experimental condition, compared to the relaxation group. Our data is consistent with the hypothesis that meditation increases pain tolerance and reduces pain intensity, however, further work is required to determine whether meditation contains similar implications for pain patients.

Beliefs about back pain and pain management behaviours, and their associations in the general population: A systematic review

Previous mass media campaigns have aimed to influence how people manage back pain, with mixed success. Campaigns should target beliefs which are related to the behaviours they aim to change. This systematic review brings together research that has measured the prevalence of beliefs about back pain in the general population and factors associated with these beliefs, including future pain‐related outcomes. Five databases were searched up until April 2017. Quantitative studies which reported a measure of agreement with a belief about back pain, cross‐sectional associations, or associations between beliefs and future outcomes were eligible. Eligibility was assessed and data extracted independently by two authors. Results were tabulated and narratively synthesized. Nineteen studies from 10 countries were eligible (median study n [IQR] = 990.5 [524.75–2387.5]). Beliefs were measured using eight questionnaires and 57 stand‐alone items. Beliefs about back pain's negative consequences were common across countries and populations, whereas most samples did not hold fear‐avoidance beliefs. Beliefs about back pain's consequences were associated with pain and disability, but only one study investigated this specific relationship prospectively. No studies investigated whether beliefs are associated with future pain management behaviours. Agreement with certain beliefs (e.g. about negative consequences) was associated with sociodemographic characteristics (e.g. older age) and poorer self‐rated health. Interventions may benefit from targeting beliefs about the perceived negative consequences of back pain in these populations. However, future research should explore how beliefs prospectively influence the management of back pain.

Significance

This review brings together studies which have assessed the prevalence of beliefs about back pain, and factors associated with holding them. It highlights that whether or not these beliefs represent important determinants of how people manage pain remains unknown.

Optimizing Placebo and Minimizing Nocebo to Reduce Pain, Catastrophizing, and Opioid Use: A Review of the Science and an Evidence-Informed Clinical Toolkit

Pain, a noxious psychosensory experience, motivates escape behavior to assure protection and survival. Psychological factors alter the experience and trajectory of pain, as well as behavior and treatment response. In the context of pain, the placebo effect (expectation for pain relief) releases endogenous opioids and facilitates analgesia from exogenously administered opioids. Nocebo hyperalgesia (expectation for persistent or worsening pain) opposes endogenous opioid analgesia and patient engagement in prescription opioid tapering. Reductions in nocebo hyperalgesia and pain catastrophizing may enhance descending modulation of pain, mediate adaptive structural brain changes and promote patient engagement in opioid tapering. Interventions that minimize nocebo and optimize placebo may adaptively shape the central nervous system toward pain relief and potentially opioid reduction. Here we provide a critical description of catastrophizing and its impact on pain, placebo and nocebo effects. We also consider the importance of minimizing nocebo and optimizing placebo effects during prescription opioid tapering, and offer a clinical toolkit of resources to accomplish these goals clinically.

Comparative Efficacy and Mechanisms of a Single-Session Pain Psychology Class in Chronic Low Back Pain: Study Protocol for a Randomized Controlled Trial

Background

The Institute of Medicine (IOM) reported that chronic pain affects about 100 million U.S. adults, with chronic low back pain (CLBP) cited as the most prevalent type. Pain catastrophizing is a psychological construct shown to predict the development and trajectory of chronic pain and patient response to pain treatments. While effective treatment for pain catastrophizing typically includes eight-session groups of cognitive behavioral therapy (CBT), a single-session targeted treatment class yielded promising results which, if replicated and extended, could prove to efficiently and cost-effectively reduce pain catastrophizing. In this trial, we seek to determine the comparative efficacy of this novel single-session pain catastrophizing class to an eight-session course of pain CBT and a single-session back pain health education class. We will also explore the psychosocial mechanisms and outcomes of pain catastrophizing treatment.

Methods

In this trial we will randomize 231 individuals with CLBP to one of three treatment arms: (1) pain-CBT (eight weekly 2-h group sessions with home exercises and readings); (2) a single 2-h pain catastrophizing class; or (3) a single 2-h back pain health education class (active control). For the primary outcome of pain catastrophizing, the trial is designed as a non-inferiority test between pain-CBT and the single-session pain catastrophizing class, and as a superiority test between the single-session pain catastrophizing class and the health education class. Team researchers masked to treatment assignment will assess outcomes up to six months post treatment.

Discussion

If the single-session targeted pain catastrophizing class is found to be an effective treatment for patients with CLBP, this low cost and low burden treatment could dismantle many of the current barriers and burdens of effective pain care. Further, elucidation of the mechanisms of pain catastrophizing treatments will facilitate future research on the topic as well as further development and refinement of treatments.

Trial registration

ClinicalTrials.gov, NCT03167086. Registered on 22 May 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2537-3) contains supplementary material, which is available to authorized users.

Management of chronic pain through pain management programmes

INTRODUCTION

Chronic pain carries significant impact and is difficult to treat with limited success. Pain management programmes (PMPs) use cognitive behavioural therapy (CBT)-based multidisciplinary rehabilitative approaches to drive functional improvement.

SOURCES OF DATA

A search was conducted using Medline and the Cochrane Library to identify published literature about PMPs or CBT to treat chronic pain.

AREAS OF AGREEMENT

PMPs have significant benefit on functioning for some patients but relatively little impact on the pain. Not all patients, nor pain types, benefit. Around a third of patients show improvement, with considerable variability.

AREAS OF CONTROVERSY

There is much heterogeneity between approaches and outcomes measured, and the extent and duration of benefit is inconsistently reported. The investment required of patients, staff and commissioners is significant. Existing data provides limited information to judge whether PMPs represent good value for each of those stakeholders.

GROWING POINTS

The British Pain Society provide guidelines for PMPs, due for revision in 2018 which may provide opportunities for greater clarity and demonstrating value. Other approaches are emerging and being evaluated.

AREAS TIMELY FOR DEVELOPING RESEARCH

Participation may have more subjective impact than objective outcomes and merits qualitative research. With a (significant) minority of patients showing improvement, research into patient and treatment selection is essential alongside longterm outcomes and sustaining benefits.

Psychosocial work factors and low back pain in taxi drivers

INTRODUCTION

Taxi drivers are at high risk for low back pain (LBP).

AIM

Identify the association between psychosocial-work factors (Job strain, Iso-strain, effort-reward imbalance [ERI], unfairness, and mental exertion) and LBP in taxi drivers.

METHODS

A cross-sectional study was done with 129 taxi drivers.

RESULTS

Approximately 63% reported LBP in the prior 12 months. Chi square or t-test analyses identified the associations between demographic, work, health, and psychosocial work factors, and self-report of LBP in the prior 12 months. Depression, perceived physical exertion, dispatcher and manager support, unfair treatment at work, and unfair treatment due to nationality were significantly associated with LBP in bivariate analyses. Multivariate logistic regression was done to identify the predictors of LBP. High dispatcher support remained the sole significant predictor for lower prevalence of LBP (OR = 0.66, P = 0.017).

CONCLUSION

Greater understanding of psychosocial work factors may aid in developing interventions to prevent LBP in taxi drivers.

The Effects of Workplace Physical Activity Programs on Musculoskeletal Pain: A Systematic Review and Meta-Analysis

This article reviews the effectiveness of physical activity (PA) interventions at the workplace to reduce musculoskeletal pain among employees and assesses the effect size of these programs using meta-analysis. Four databases (i.e., PubMed, EBSCO, Web of Science, and Cochrane) were searched for research trials, which included comparison groups of employees that assessed PA programs, musculoskeletal pain, and health-related behaviors, published between January 1990 and March 2013. The meta-analysis estimates of standardized mean differences (Hedges' g) present significant evidence of less general pain (g = -.40 with a 95% confidence interval [CI] = [-0.78, -0.02]) and neck and shoulder pain (g = -.37 with a 95% CI = [-0.63, -0.12]) in intervention groups. The few studies of low back pain and arm, elbow, wrist, hand, or finger pain did not present sufficient statistically significant evidence. Consistent evidence demonstrates that workplace PA interventions significantly reduce general musculoskeletal pain and neck and shoulder pain. More studies are needed to determine the effectiveness of work-related PA interventions for arm, elbow, wrist, hand or finger, and low back pain.

Effects of a Pain Catastrophizing Induction on Sensory Testing in Women with Chronic Low Back Pain: A Pilot Study

Pain catastrophizing, a pattern of negative cognitive-emotional responses to actual or anticipated pain, maintains chronic pain and undermines response to treatments. Currently, precisely how pain catastrophizing influences pain processing is not well understood. In experimental settings, pain catastrophizing has been associated with amplified pain processing. This study sought to clarify pain processing mechanisms via experimental induction of pain catastrophizing. Forty women with chronic low back pain were assigned in blocks to an experimental condition, either a psychologist-led 10-minute pain catastrophizing induction or a control (10-minute rest period). All participants underwent a baseline round of several quantitative sensory testing (QST) tasks, followed by the pain catastrophizing induction or the rest period, and then a second round of the same QST tasks. The catastrophizing induction appeared to increase state pain catastrophizing levels. Changes in QST pain were detected for two of the QST tasks administered, weighted pin pain and mechanical allodynia. Although there is a need to replicate our preliminary results with a larger sample, study findings suggest a potential relationship between induced pain catastrophizing and central sensitization of pain. Clarification of the mechanisms through which catastrophizing affects pain modulatory systems may yield useful clinical insights into the treatment of chronic pain.

[Neglect-like symptoms after operations on the upper extremities]

BACKGROUND

Neglect-like symptoms (NLS) describe the experience of perceiving a limb as foreign and could be detected in chronic pain disorders as well as after knee joint replacement. The aim of the present study was to find out whether patients with and without NLS after surgery of the upper extremities differ with respect to pain intensity and psychosocial variables and if NLS are associated with chronic postoperative pain (CPSP).

METHODS

In this study 241 patients were interviewed using a validated questionnaire preoperatively as well as 1 day, 4 weeks, 3 months and 6 months postoperatively. Patients with and without NLS were compared using the χ²-test or Mann-Whitney U‑test. The level of significance was adjusted for multiple testing.

RESULTS

The NLS could be found to a slight extent throughout the entire study period. Patients with NLS showed significantly higher maximum pain scores at every measurement time point: average difference (∆ = 3, adjusted p < 0.005), a higher impairment due to pain (∆ = 15, adjusted p < 0.005), more anxiety (∆ = 3, adjusted p < 0.005), depression (∆ = 3, average adjusted p < 0.003) and kinesiophobia (∆ = 4, preoperative not significant, average postoperative adjusted p = 0.004). Preoperatively, more stressful life events (p = 0.002) and higher stress values (p < 0.001) were reported. In patients with CPSP, NLS occurred significantly more often (74%) than in patients without clinically relevant pain (17.5%. p < 0.001).

CONCLUSION

The occurrence of NLS is associated with higher pain scores, more impairment due to pain and a higher psychosocial burden and they are more frequent in patients with CPSP. Further investigations are needed to show if NLS are an independent risk factor for the chronification of pain and if NLS play an independent role in the pathogenesis of pain.

Effectiveness of a biopsychosocial e-learning intervention on the clinical judgements of medical students and GP trainees regarding future risk of disability in patients with chronic lower back pain: study protocol for a randomised controlled trial

INTRODUCTION

Chronic lower back pain (CLBP) is a major healthcare problem with wide ranging effects. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions that identify biopsychosocial barriers to recovery have been observed to lead to successfully reduced pain-related work absences and increased return to work for individuals with CLBP. Modern conceptualisations of pain adopt a biopsychosocial approach, such as the flags approach. Biopsychosocial perspectives have been applied to judgements about future adjustment, recovery from pain and risk of long-term disability; and provide a helpful model for understanding the importance of contextual interactions between psychosocial and biological variables in the experience of pain. Medical students and general practitioner (GP) trainees are important groups to target with education about biopsychosocial conceptualisations of pain and related clinical implications.

AIM

The current study will compare the effects of an e-learning intervention that focuses on a biopsychosocial model of pain, on the clinical judgements of medical students and trainees.

METHODS AND ANALYSIS

Medical student and GP trainee participants will be randomised to 1 of 2 study conditions: (1) a 20 min e-learning intervention focused on the fundamentals of the flags approach to clinical judgement-making regarding risk of future pain-related disability; compared with a (2) wait-list control group on judgement accuracy and weighting (ie, primary outcomes); flags approach knowledge, attitudes and beliefs towards pain, judgement speed and empathy (ie, secondary outcomes). Participants will be assessed at preintervention and postintervention.

ETHICS AND DISSEMINATION

The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Ireland Galway Research Ethics Committee. The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN53670726; Pre-results.

Symptoms of Depression and Risk of New Episodes of Low Back Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the contribution of symptoms of depression to future episodes of low back pain (LBP).

METHODS

A search was conducted of AMED, CINAHL, Embase, Health and Society (H&S), LILACS, MEDLINE, PsycINFO, Scopus, and Web of Science databases. We included cohort studies investigating the effect of symptoms of depression on the development of new episodes of LBP, either lifetime incidence or a recurrent episode, in a population free of LBP at baseline. We accepted the original study's definition for a new episode of LBP, and for classifying patients as LBP-free at study entry. Two independent investigators extracted data and assessed methodological quality. Meta-analyses with random effects were used to pool risk estimates.

RESULTS

We included 19 studies, with 11 incorporated in the meta-analyses. Overall pooled results showed that symptoms of depression increased the risk of developing LBP (odds ratio [OR] 1.59, 95% confidence interval [95% CI] 1.26-2.01). The risk was similar in studies that used the diagnostic interview method (OR 1.66, 95% CI 1.14-2.42) and in studies using self-report screening questionnaires (OR 1.68, 95% CI 1.05-2.70). No statistically significant relationship was observed when we pooled studies that employed nonspecific screening questionnaires (OR 1.17, 95% CI 0.48-2.87). Three studies provided results in incremental categories of symptoms of depression and the pooled OR for the most severe level of depression (OR 2.51, 95% CI 1.58-3.99) was higher than for the lowest level (OR 1.51, 95% CI 0.89-2.56).

CONCLUSION

Individuals with symptoms of depression have an increased risk of developing an episode of LBP in the future, with the risk being higher in patients with more severe levels of depression.

Pain Psychology: A Global Needs Assessment and National Call to Action

OBJECTIVE

The Institute of Medicine and the draft National Pain Strategy recently called for better training for health care clinicians. This was the first high-level needs assessment for pain psychology services and resources in the United States.

DESIGN

Prospective, observational, cross-sectional.

METHODS

Brief surveys were administered online to six stakeholder groups (psychologists/therapists, individuals with chronic pain, pain physicians, primary care physicians/physician assistants, nurse practitioners, and the directors of graduate and postgraduate psychology training programs).

RESULTS

1,991 responses were received. Results revealed low confidence and low perceived competency to address physical pain among psychologists/therapists, and high levels of interest and need for pain education. We found broad support for pain psychology across stakeholder groups, and global support for a national initiative to increase pain training and competency in U.S. therapists. Among directors of graduate and postgraduate psychology training programs, we found unanimous interest for a no-cost pain psychology curriculum that could be integrated into existing programs. Primary barriers to pain psychology include lack of a system to identify qualified therapists, paucity of therapists with pain training, limited awareness of the psychological treatment modality, and poor insurance coverage.

CONCLUSIONS

This report calls for transformation within psychology predoctoral and postdoctoral education and training and psychology continuing education to include and emphasize pain and pain management. A system for certification is needed to facilitate quality control and appropriate reimbursement. There is a need for systems to facilitate identification and access to practicing psychologists and therapists skilled in the treatment of pain.

Psychometric properties of the Brazilian version of the Pain Catastrophizing Scale for acute low back pain

Measurement instruments of pain catastrophizing for middle-aged and elderly individuals are needed to understand its impact on low back pain. The goals were to cross-culturally adapt the Pain Catastrophizing Scale, assess the construct validity through Rasch analysis, and verify reliability and convergent validity of pain catastrophizing with psychosocial factors. 131 individuals aged 55 years and older with acute low back pain were interviewed . The intra-rater reliability was Kp = 0.80 and interrater Kp = 0.75. The Rasch analysis found adequate reliability coefficients (0.95 for items and 0.90 for individuals ). The separation index for the elderly was 2.95 and 4.59 items. Of the 13 items, one did not fit the model, which was justified in the sample evaluated. The pain catastrophizing correlated with most psychosocial factors. The instrument proved to be clinically useful. Subsequent studies should carry out the same analysis in different populations.

Epidemiology of low back pain in adults

OBJECTIVE

Low back pain affects many individuals. It has profound effects on well-being and is often the cause of significant physical and psychological health impairments. Low back pain also affects work performance and social responsibilities, such as family life, and is increasingly a major factor in escalating health-care costs. A global review of the prevalence of low back pain in the adult general population has shown its point prevalence to be approximately 12%, with a one-month prevalence of 23%, a one-year prevalence of 38%, and a lifetime prevalence of approximately 40%. Furthermore, as the population ages over the coming decades, the number of individuals with low back pain is likely to increase substantially. This comprehensive review is undertaken to assess the increasing prevalence of low back pain and the influence of comorbid factors, along with escalating costs.

MATERIALS AND METHODS

A narrative review with literature assessment.

RESULTS

In the USA, low back pain and related costs are escalating. Based on the available literature, it appears that the prevalence of low back pain continues to increase, along with numerous modalities and their application in managing low back pain. Comorbid factors with psychological disorders and multiple medical problems, including obesity, smoking, lack of exercise, increasing age, and lifestyle factors, are considered as risk factors for low back pain.

CONCLUSION

Although it has been alleged that low back pain resolves in approximately 80% to 90% of patients in about six weeks, irrespective of the administration or type of treatment, with only 5% to 10% of patients developing persistent back pain, this concept has been frequently questioned as the condition tends to relapse and most patients experience multiple episodes years after the initial attack.

Pre-employment examination for low back risk in workers exposed to manual handling of loads: French guidelines

BACKGROUND

Low back pain (LBP) is a major cause of sickness absence and disability in the working population, and the pre-employment examination should insure that worker's state of health is compatible with the requirements of proposed job. This paper summarizes the main recommendations of the good practice guidelines of the French Society of Occupational Medicine for pre-employment examination in workers exposed to manual handling of loads apart from pre-employment test.

METHODS

The recommendations were developed according to the Clinical Practice Guidelines proposed by the French National Health Authority and based on a systematic search of the literature 1990-2012 in several databases. The guidelines were written and reviewed by two multidisciplinary committees. On the basis of the level of evidence in the literature, the proposed guidelines are classified as grade A, B, C or expert consensus.

RESULTS

The main recommendations of these guidelines are as follows: (1) medical contraindications alone should not exclude employment in a job associated with a low back risk on the basis of a history of "simple" nonspecific LBP; (2) the relevance of examining a previous history of LBP, which is the best predictor of future LBP due to the recurrent nature of LBP.

CONCLUSIONS

These guidelines correspond to a constant concern with prevention of occupational risk. Primarily intended for occupational physicians, they are also intended for general practitioners who carry out pre-employment examinations in many countries and are likely to be increasingly faced with this type of situation because of the combination of increasing work constraints with ageing of the workforce.

Interaction between physical and psychosocial work risk factors for low back symptoms and its consequences amongst Indonesian coal mining workers

This study assessed the interaction between physical and psychosocial factors for low back symptoms (LBS) and its consequences (reduced activities and absenteeism) in a developing country. A sample of 1294 Indonesian coal mining workers reported occupational exposures, LBS and its consequences using a self-administered questionnaire. Respondents were placed into one of four combination exposure groups: high physical and high psychosocial (HPhyHPsy); high physical and low psychosocial (HPhyLPsy); low physical and high psychosocial (LPhyHPsy), and; low physical and low psychosocial (LPhyLPsy). The attributable proportion due to interaction between physical and psychosocial factors was examined. Individuals in the HPhyHPsy group were most likely to report LBS (OR 5.42, 95% CI 3.30-8.89), reduced activities (OR 4.89, 95% CI 3.09-7.74), and absenteeism (OR 4.96, 95% CI 3.05-8.06). Interactions between physical and psychosocial factors were present for LBS, reduced activities, and absenteeism; although for LBS and absenteeism the interactions were not significant. Current smokers were more likely to report LBS consequences. Permanent employment and night shift work increased the odds of LBS and its consequences. We conclude that interventions aimed at reducing LBS and its consequences should address both physical and psychosocial factors, with a focus on smokers, permanent employment and night shift work.

The combined effect of physical, psychosocial/organisational and/or environmental risk factors on the presence of work-related musculoskeletal symptoms and its consequences

This study assessed the combined effect of physical and psychosocial/organisational and/or environmental factors on the presence of musculoskeletal symptoms (MSS) and its consequences (reduced activities and absenteeism due to MSS) in a random sample of 3003 workers in New Zealand. By telephone interview, participants reported their current workplace exposures and MSS (neck/shoulder, arm/elbow, wrist and low back) and its consequences. Data were analysed using multivariable logistic regression. Combined exposure to physical and psychosocial/organisational and/or environmental factors increased the odds of MSS in the neck/shoulder (OR 3.14, 95% CI 1.79-5.52), arms/elbow regions (OR 4.14, 95% CI 2.21-7.76) and low back (OR 1.74, 95% CI 1.28-2.37) and its consequences, i.e. reduced activities due to neck/shoulder symptoms (OR 5.45, 95% CI 2.28-13.00), absenteeism due to neck/shoulder symptoms (OR 5.19, 95% CI 2.24-12.01) and absenteeism due to low back symptoms (OR 4.37, 95% CI 2.92-6.53). In contrast, favourable psychosocial/organisational work conditions reduced the odds of wrist symptoms due to poor physical work conditions (OR 2.19, 95% CI 1.44-3.34). We conclude that to reduce MSS and its consequences, employers need to adopt a multifaceted approach: concentrate on improving physical conditions as well as the psychosocial/organisational and environmental aspects of the working environment.

From Catastrophizing to Recovery: a pilot study of a single-session treatment for pain catastrophizing

Background

Pain catastrophizing (PC) – a pattern of negative cognitive-emotional responses to real or anticipated pain – maintains chronic pain and undermines medical treatments. Standard PC treatment involves multiple sessions of cognitive behavioral therapy. To provide efficient treatment, we developed a single-session, 2-hour class that solely treats PC entitled “From Catastrophizing to Recovery” [FCR].

Objectives

To determine 1) feasibility of FCR; 2) participant ratings for acceptability, understandability, satisfaction, and likelihood to use the information learned; and 3) preliminary efficacy of FCR for reducing PC.

Design and methods

Uncontrolled prospective pilot trial with a retrospective chart and database review component. Seventy-six patients receiving care at an outpatient pain clinic (the Stanford Pain Management Center) attended the class as free treatment and 70 attendees completed and returned an anonymous survey immediately post-class. The Pain Catastrophizing Scale (PCS) was administered at class check-in (baseline) and at 2, and 4 weeks post-treatment. Within subjects repeated measures analysis of variance (ANOVA) with Student’s t-test contrasts were used to compare scores across time points.

Results

All attendees who completed a baseline PCS were included as study participants (N=57; F=82%; mean age =50.2 years); PCS was completed by 46 participants at week 2 and 35 participants at week 4. Participants had significantly reduced PC at both time points (P<0001) and large effect sizes were found (Cohen’s d=0.85 and d=1.15).

Conclusion

Preliminary data suggest that FCR is an acceptable and effective treatment for PC. Larger, controlled studies of longer duration are needed to determine durability of response, factors contributing to response, and the impact on pain, function and quality of life.

Influence of low back pain on total knee arthroplasty outcome

BACKGROUND

Preoperative pain and functional status are strong determinants of postsurgical success in total knee arthroplasty. Patients suffering chronic pain from other coexistent musculoskeletal problems may respond differently postoperatively, with potentially poorer outcomes after surgery. The aim of the study was to determine the influence of low back pain on the outcome of total knee replacement surgery.

METHODS

All patients completed Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 (both physical and mental components). Patients were divided into those with (n=40) and without a documented history of low back pain (n=305).

RESULTS

OKS, AKSS and SF-12 physical scores were significantly worse for patients with low back pain at 24 months following surgery. The mental component of the SF-12 measure demonstrated a significant improvement in median mental health post-operatively for patients with no current history of low back pain. In contrast the group with low back pain showed no improvement in mental health scores post-operatively.

CONCLUSION

This study demonstrates that symptomatic low back pain influences functional outcome after total knee arthroplasty surgery and that patients with low back pain show limited or no improvement in mental health post-operatively. Level of evidence II.

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.

Psychological factors associated with development of TMD: the OPPERA prospective cohort study

Case-control studies have consistently associated psychological factors with chronic pain in general and with temporomandibular disorder (TMD) specifically. However, only a handful of prospective studies have explored whether preexisting psychological characteristics represent risk factors for first-onset TMD. The current findings derive from the prospective cohort study of the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) cooperative agreement. For this study, 3,263 TMD-free participants completed a battery of psychological instruments assessing general psychological adjustment and personality, affective distress, psychosocial stress, somatic symptoms, and pain coping and catastrophizing. Study participants were then followed prospectively for an average of 2.8 years to ascertain cases of first-onset of TMD, and 2,737 provided follow-up data and were considered in the analyses of TMD onset. In bivariate and demographically adjusted analyses, several psychological variables predicted increased risk of first-onset TMD, including reported somatic symptoms, psychosocial stress, and affective distress. Principal component analysis of 26 psychological scores was used to identify latent constructs, revealing 4 components: stress and negative affectivity, global psychological and somatic symptoms, passive pain coping, and active pain coping. In multivariable analyses, global psychological and somatic symptoms emerged as the most robust risk factor for incident TMD. These findings provide evidence that measures of psychological functioning can predict first onset of TMD. Future analyses in the OPPERA cohort will determine whether these psychological factors interact with other variables to increase risk for TMD onset and persistence.

PERSPECTIVE

This article reports that several premorbid psychological variables predict first-onset TMD in the OPPERA study, a large prospective cohort study designed to discover causal determinants of TMD pain. Measures of somatic symptoms were most strongly associated with TMD onset, but perceived stress, previous life events, and negative affect also predicted TMD incidence.

["Back pain coach". A project for patients with back pain]

QUESTION

Back pain is a challenge for case management but is a health insurance fund (HIF) that identifies high risk patients and includes them in a back pain assessment and a multimodal program cost-effective?

METHODS

Case managers of a HIF contacted selected patients and requested information on pain and current perspectives. Patients in the intervention group were offered a multimodal assessment and, if applicable, a multimodal treatment program. Control group patients received verbal or written (back book) information. Cost data were evaluated with respect to the interview data 1 year prior and 1 year afterwards.

FINDINGS

Of the 800 insured persons contacted 621 were nationwide, 88 were regional controls and 91 were intervention patients. Inability to work was still rising in all groups but less in the intervention group versus both control groups. Drugs, hospital as well as cure/adjuvant costs were less for intervention patients than in both control groups. The investment for the program was thus more than refinanced.

INTERPRETATION

Case management was well accepted but the intervention was in need of training for case managers and the specific diagnostic and treatment option regionally.

FUNDING

The HIF was responsible for the study investment and project partners shared the training of the HIF regional case managers.

Low back pain across the life course

Back pain episodes are traditionally regarded as individual events, but this model is currently being challenged in favour of treating back pain as a long-term or lifelong condition. Back pain can be present throughout life, from childhood to older age, and evidence is mounting that pain experience is maintained over long periods: for example, people with pain continue to have it on and off for years, and people without pain do not suddenly develop long-term pain. A number of factors predict back pain presence in epidemiological studies, and these are often present, and predictive, at different life stages. There are also factors present at particular life stages, such as childhood or adolescence, which predict back pain in adulthood. However, there are little published data on long-term pain patterns or predictors over the life course. Such studies could improve our understanding of the development and fluctuations in back pain, and therefore influence treatment approaches.

Physical and psychosocial risk factors for musculoskeletal disorders in Brazilian and Italian nurses

As part of the international CUPID investigation, we compared physical and psychosocial risk factors for musculoskeletal disorders among nurses in Brazil and Italy. Using questionnaires, we collected information on musculoskeletal disorders and potential risk factors from 751 nurses employed in public hospitals. By fitting countryspecific multiple logistic regression models, we investigated the association of stressful physical activities and psychosocial characteristics with site-specific and multisite pain, and associated sickness absence. We found no clear relationship between low back pain and occupational lifting, but neck and shoulder pain were more common among nurses who reported prolonged work with the arms in an elevated position. After adjustment for potential confounding variables, pain in the low back, neck and shoulder, multisite pain, and sickness absence were all associated with somatizing tendency in both countries. Our findings support a role of somatizing tendency in predisposition to musculoskeletal disorders, acting as an important mediator of the individual response to triggering exposures, such as workload.

Patient expectations of benefit from interventions for neck pain and resulting influence on outcomes

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

The objectives of this study were (1) to examine patients' general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain, and (2) to assess the extent to which the patients' general and specific expectations for treatment, particularly spinal manipulation, affect clinical outcomes.

BACKGROUND

Patient expectations can have a profound influence on the magnitude of treatment outcome across a broad variety of patient conditions.

METHODS

We performed a secondary analysis of data from a clinical trial of interventions for neck pain. Prior to beginning treatment for neck pain, 140 patients were asked about their general expectations of benefit as well as their specific expectations for individual interventions. Next, we examined how these expectations related to the patients' ratings of the success of treatment at 1 and 6 months after treatment.

RESULTS

Patients had positive expectations for treatment by a physical therapist, with more than 80% of patients expecting moderate relief of symptoms, prevention of disability, the ability to do more activity, and to sleep better. The manual therapy interventions of massage (87%) and manipulation (75%) had the highest proportion of patients who expected these interventions to significantly improve neck pain. These were followed by strengthening (70%) and range-of-motion (54%) exercises. Very few patients thought surgery would improve their neck pain (less than 1%). At 1 month, patients who were unsure of experiencing complete pain relief had lower odds of reporting a successful outcome than patients expecting complete relief (odds ratio [OR] = 0.33; 95% confidence interval [CI]: 0.11, 0.99). Believing that manipulation would help and not receiving manipulation lowered the odds of success (OR = 0.16; 95% CI: 0.04, 0.72) compared to believing manipulation would help and receiving manipulation. Six months after treatment, having unsure expectations for complete pain relief lowered the odds of success (OR = 0.19; 95% CI: 0.05, 0.7), whereas definitely expecting to do more exercise increased the odds of success (OR = 11.4; 95% CI: 1.7, 74.7). Regarding self-reported disability assessed with the Neck Disability Index, patients who believed manipulation would help and received manipulation reported less disability than those who did not believe manipulation would help and both received manipulation (mean difference, -3.8; 95% CI: -5.9, -1.5; P = .006) and did not receive manipulation (mean difference, -5.7; 95% CI: -9.3, -2.1; P = .014). There was also an interaction between time and the expectation for complete relief.

CONCLUSION

General expectations of benefit have a strong influence on clinical outcomes for patients with neck pain.

LEVEL OF EVIDENCE

Prognosis, level 2b-.

Affect balance style, experimental pain sensitivity, and pain-related responses

OBJECTIVES

Affect is neurobiologically based, influences emotions, contributes to temperamental characteristics, and can be evaluated from both state and trait perspectives. Associations between state-related positive affect (PA), negative affect (NA), and chronic pain have been investigated. However, little is known about the relationship between trait affect patterns and pain-related experiences. Affect balance style (ABS) provides a framework to assess the combined contribution of trait PA and NA. Psychological factors and experimental pain sensitivity are indicated as predictors of chronic pain onset. The current study investigated the relationship between ABS, pain sensitivity, and pain-related measures in healthy adults.

METHODS

Participants (n=372) completed quantitative sensory testing, pain-related questionnaires, and the Positive and Negative Affect Scale. ABS groups were categorized as Healthy (high PA, low NA), Low (low PA, low NA), Depressive (low PA, high NA), and Reactive (high PA, high NA). Z-scores were computed for 3 experimental pain measures: ischemic, pressure, and heat.

RESULTS

ABS groups significantly differed on ischemic pain sensitivity and pain-related measures. Specifically, the Healthy group demonstrated lower ischemic pain sensitivity compared with the Reactive group (P=0.02); the Depressive and Reactive groups endorsed higher somatic symptoms compared with the Healthy group (P<0.02); the Low and Depressive groups reported more physical stimuli sensitivity than the Healthy group (P<0.02); and the Reactive group indicated more passive coping strategies then the Low and Healthy groups (P=0.001).

DISCUSSION

Findings from the study suggest that among healthy adults, trait affect patterns are associated with ischemic experimental pain sensitivity and other pain-related measures.

Potential psychosocial risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case-control study

Case-control studies have consistently associated psychosocial factors with chronic pain in general, and with temporomandibular disorders (TMD) specifically. Moreover, a handful of prospective studies suggest that preexisting psychosocial characteristics represent risk factors for new onset TMD. The current study presents psychosocial findings from the baseline case-control study of the Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) cooperative agreement. For this study, 1,633 TMD-free controls and 185 TMD cases completed a battery of psychosocial instruments assessing general psychosocial adjustment and personality, affective distress, psychosocial stress, somatic awareness, and pain coping and catastrophizing. In bivariate and demographically adjusted analyses, odds of TMD were associated with higher levels of psychosocial symptoms, affective distress, somatic awareness, and pain catastrophizing. Among controls, significant gender and ethnic group differences in psychosocial measures were observed, consistent with previous findings. Principal component analysis was undertaken to identify latent constructs revealing 4 components: stress and negative affectivity, global psychosocial symptoms, passive pain coping, and active pain coping. These findings provide further evidence of associations between psychosocial factors and TMD. Future prospective analyses in the OPPERA cohort will determine if the premorbid presence of these psychosocial factors predicts increased risk for developing new onset TMD.

PERSPECTIVE

This article reports baseline psychosocial findings from the OPPERA Study, a large prospective cohort study designed to discover causal determinants of TMD pain. Findings indicate significant differences between TMD cases and TMD-free controls across multiple psychosocial constructs, and future analyses will determine whether these psychosocial factors increase risk for new onset TMD.

Back pain among farmers in a northern area of China

STUDY DESIGN

This was a population-based survey conducted in 2008 in a northern area of China.

OBJECTIVE

To investigate back pain prevalence and to examine the associations between potential risk factors and back pain among Chinese farmers.

SUMMARY OF BACKGROUND DATA

Few studies have investigated back pain and its associated risk factors among farmers in low-income and developing nations.

METHODS

Farmers ages 15 years and older were chosen from 800 families in Heilongjiang province of the People's Republic of China using cluster sampling methods. Complete survey data were obtained from 2045 farmers. The prevalence of self-reported back pain during the previous 3 months was reported. Associations between back pain and potential risk factors, which included age, gender, education levels, perceived stress, main farm activities, smoking, and drinking status, were examined in logistic regression models.

RESULTS

A total of 786 (38.4%) farmers reported back pain. Two-thirds of those with back pain (66.0%) reported that back pain affected work quantity and quality. The adjusted odds ratios of reporting back pain increased with advancing age. Females and farmers who experienced stress regularly were also more likely to report back pain.

CONCLUSION

Back pain is a common problem among Chinese farmers and is reported more frequently by females. Significant positive associations of gender, age, and perceived stress with back pain warrant additional study.