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

Associations between the perception of dental pain and pain anxiety, mental pain, and dental anxiety in Iranian sample

OBJECTIVE

This study examined the perception of dental pain and its relationship to pain anxiety, dental anxiety, and mental pain.

METHODS

This cross-sectional study was conducted on 328 patients referred to dental clinics in Kermanshah (Iran) from 2020 to 2021. The instruments used in this study included scales assessing pain anxiety, dental anxiety, mental pain, and pain perception.

RESULTS

There was a significant relationship (p = .001) between pain perception with dental anxiety (r = .38), pain anxiety (r = .45), and mental pain (r = .25).

CONCLUSION

Psychological factors are associated with the perception of dental pain. Given the importance of dental care to overall health, psychological interventions may help to reduce the perception of dental pain and fear of seeing dentists in Iran.

Biopsychosocial contributors to irritability in individuals with shoulder or low back pain

OBJECTIVES

Irritability is a foundational clinical reasoning concept in rehabilitation to evaluate reactivity of the examination and treatment. While originally theorized to reflect tissue damage, a large body of evidence supports pain is a biopsychosocial experience impacted by pain sensitivity and psychological factors. Therefore, the purpose of this study was to examine biopsychosocial contributors to irritability.

METHODS

40 patients with shoulder (n = 20) and low back (n = 20) pain underwent Quantitative Sensory Testing (QST) (Pressure Pain Threshold, Heat Pain Threshold, Conditioned Pain Modulation, Temporal Summation), completed pain-related psychological questionnaires, an Exercise-Induced Hypoalgesia protocol, and standardized irritability assessment based on Clinical Practice Guidelines. Participants were then categorized as irritable or not irritable based on Maitland's criteria and by irritability level based on Clinical Practice Guidelines. An independent samples t-test examined for differences in QST and psychological factors by irritability category. A MANOVA examined for differences in QST and psychological factors by irritability level (high, moderate, low).

RESULTS

Significantly lower heat and pressure pain thresholds at multiple locations (p < 0.05), as well as less efficient conditioned pain modulation (p = 0.02), were demonstrated in individuals categorized as irritable. Heat and pressure pain thresholds were also significantly lower in patients with high irritability compared to other levels. Significantly higher depression and anger, as well as lower self-efficacy, were reported in individuals with an irritable presentation.

DISCUSSION/CONCLUSION

Biopsychosocial factors, including widespread hyperalgesia and elevated psychological factors, may contribute to an irritable presentation.

Effect of integrated exercise therapy and psychosocial interventions on self-efficacy in patients with chronic low back pain: A systematic review

OBJECTIVE

Investigate if integrated exercise and psychosocial (EP) interventions effect self-efficacy to manage pain and self-efficacy for physical functioning compared to alternate interventions, usual care, waitlists and attention controls for individuals with chronic low back pain (CLBP).

METHODS

MEDLINE, Embase, CINAHL, Web of Science, PsychINFO, PEDro, and Cochrane Library were searched. Included randomized controlled trials utilized an EP intervention for CLBP and measured self-efficacy. Independent reviewers screened abstracts, reviewed full-texts, extracted data, and assessed risk of bias. GRADE, synthesis without meta-analysis, and ranges of effects (Hedges' g) were used.

RESULTS

2207 Participants were included (22-studies). EP interventions positively effected self-efficacy to manage pain short-term compared to usual care (range of effects: -0.02, 0.94) and controls (range of effects: 0.69, 0.80) and intermediately compared to usual care (range of effects: 0.11, 0.29); however, no differences were found when compared to alternate interventions. EP interventions positively effected self-efficacy for physical functioning short-term compared to alternate interventions (range of effects: 0.57, 0.71), usual care (range of effects: -0.15, 0.94), and controls (range of effects: 0.31, 0.56), and intermediately compared to alternate interventions (1-study, effect: 0.57) and controls (1-study, effect: 0.56). Conclusions were limited by low to very low-quality-evidence often from risk of bias, imprecision, and clinical/statistical heterogeneity.

CONCLUSIONS

EP interventions may be more effective short-term for self-efficacy to manage pain than usual care and waitlists, but not alternate interventions. EP interventions may be effective for self-efficacy for physical functioning at short- and intermediate-term compared to alternate interventions, usual care, waitlist and attention controls. Considerations for future research include methods for blinding and measurement of self-efficacy for physical functioning.

The association between self-efficacy on function and pain outcomes among patients with chronic low back pain managed using the McKenzie approach: a prospective cohort study

INTRODUCTION

Self-efficacy is a determinant of function and pain outcomes in patients with chronic low back pain receiving physiotherapy. The McKenzie approach is an effective intervention for patients with back pain that may affect self-efficacy. Study aims were to determine if, among patients with back pain being managed by McKenzie-credentialed physiotherapists: intake self-efficacy is correlated with intake function and pain; intake self-efficacy is associated with changes in function and pain during treatment; self-efficacy improves during treatment; and improvements in self-efficacy during treatment are associated with improvements in function and pain at discharge.

METHODS

Two-hundred-eighty-two subjects with chronic low back pain seen by McKenzie-credentialed clinicians provided data on self-efficacy, function and pain at intake and discharge.

RESULTS

Self-efficacy was correlated with function and pain at intake; however, intake self-efficacy was not associated with function or pain outcomes. Self-efficacy increased during treatment. This increase was associated with improvements in function and pain at discharge.

CONCLUSION

While intake self-efficacy was associated with function and pain when initiating physiotherapy, it did not result in improved treatment outcomes. Specific interventions may be necessary to improve self-efficacy. The increases in self-efficacy observed during treatment were associated with improvements in function and pain outcomes at discharge.

The effect of exercise engagement on low back disability at 12-months is mediated by pain and catastrophizing in a community sample of people with chronic low back pain

Despite being a first-line treatment recommendation, there is uncertainly for how exercise helps people with chronic low back pain. We designed this study to examine how exercise might help people with chronic low back pain by following a large community sample for 1-year. Qualitative questionnaires and self-report measures were collected every 3-months for 1-year in 400 people with chronic low back pain. People were not provided any specific treatment advice as part of this study but were allowed to engage with any normal physical activity, treatment, or medication as part of their normal life. Exercise engagement was defined from inspection of participant qualitative responses, according to minimum acceptable levels of exercise that elicit symptom reduction. Multiple mediation analysis was performed to examine the effect of exercise engagement on disability through the proposed mediators (pain, fear, catastrophizing, depression, anxiety, self-efficacy). The significant effect of exercise engagement on reductions in disability at 6- and 12-months was explained through pain and catastrophizing. People with chronic low back pain who reported worsening of symptoms over the year had similar reporting of exercise throughout the 12-months to people who had improvements in disability. Exercise can reduce disability through the effect on pain and catastrophizing, but how this effect occurs (i.e., an active or passive component of exercise) is unclear.

Feasibility, Usability, and Implementation Context of an Internet-Based Pain Education and Exercise Program for Chronic Musculoskeletal Pain: Pilot Trial of the ReabilitaDOR Program

Background

Internet-based self-management programs and telerehabilitation initiatives have increased and have been extensively used for delivering health care in many areas. These programs overcome common barriers that patients face with traditional face-to-face health care, such as travel expenditures, lack of time, and high demand on the public health system. During the COVID-19 pandemic, this mode of web-based health care delivery had become more popular. However, there is still a lack of studies testing this mode of delivery in low- and middle-income countries. To gain a better understanding of the context, feasibility, and factors involved in the implementation of a web-based program, pilot and implementation studies are necessary. These studies can better inform whether a strategy is feasible, acceptable, and adequate for its purposes and for optimizing resource allocation.

Objective

This study aims to evaluate the feasibility, usability, and implementation context of a self-management internet-based program based on exercises and pain education (ReabilitaDOR) in people with chronic musculoskeletal pain and to compare this program with a program using only a web-based self-management booklet.

Methods

The study design was a parallel pilot study of a prospectively registered, assessor-blinded, 2-arm randomized controlled trial with economic evaluation. This study was performed using waiting lists of physiotherapy and rehabilitation centers and advertisements on social media networks. The participants were 65 patients with chronic musculoskeletal pain aged between 18 and 60 years. The effects of an 8-week telerehabilitation program based on exercises and pain education (intervention group) were compared with those of a program based only on a web-based self-management booklet (control group). The main outcome measures were implementation outcomes of patients’ perceptions of acceptability, appropriateness, feasibility, and usability of the program and the societal costs and feasibility of the main trial at 8-week posttreatment follow-up. Adverse events were also analyzed.

Results

In total, 56 participants were analyzed at the 8-week follow-up. The intervention group showed responses with a mean of 4.5 (SD 0.6) points for acceptability, 4.5 (SD 0.5) points for appropriateness, and 4.5 (SD 0.6) points for feasibility measured on a 1 to 5 scale. All patients in the intervention group showed satisfactory responses to the system usability outcome. There is satisfactory evidence for the feasibility of the main trial. For costs related to the interventions, health care, patients, and loss of productivity at 8 weeks, we found a total expenditure of US $278.30 per patient in the intervention group and US $141.52 per patient in the control group. No adverse events were reported during the intervention period.

Conclusions

We found that the ReabilitaDOR program is feasible, appropriate, and acceptable from the users’ implementation perspective. This system was considered usable by all the participants, and the main trial seemed feasible. Cost data were viable to be collected, and the program is likely to be safe.

Trial Registration

ClinicalTrials.gov NCT04274439; https://clinicaltrials.gov/ct2/show/NCT04274439

Are Morphometric and Biomechanical Characteristics of Lumbar Multifidus Related to Pain Intensity or Disability in People With Chronic Low Back Pain After Considering Psychological Factors or Insomnia?

INTRODUCTION

Lumbar multifidus muscle (LMM) dysfunction is thought to be related to pain and/or disability in people with chronic low back pain (CLBP). Although psychosocial factors play a major role in pain/disability, they are seldom considered as confounders in analyzing the association between LMM and CLBP.

OBJECTIVES

This study aimed to determine: (1) differences in psychological factors, insomnia, and LMM characteristics between people with and without CLBP; (2) associations between psychological factors, insomnia, or LMM characteristics and low back pain (LBP) intensity or LBP-related disability in people with CLBP; and (3) whether LMM characteristics are related to LBP symptoms in people with CLBP after considering confounders.

METHODS

Seventy-eight volunteers with CLBP and 73 without CLBP provided sociodemographic information, filled the 11-point numeric pain rating scale and Roland-Morris disability questionnaire (RMDQ). They completed the Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), Fear Avoidance Belief Questionnaire (FAB), and Insomnia Severity Index Scale (ISI). Resting and contracted thickness of LMM at L4-S1 levels were measured from brightness-mode ultrasound images. Percent thickness changes of LMM at L4-S1 levels during contraction were calculated. Resting LMM stiffness at L4-S1 was measured by shear wave elastography. Associations among LMM, psychosocial or insomnia parameters and clinical outcomes were analyzed by univariate and multivariate analyses.

RESULTS

People with CLBP demonstrated significantly higher LBP-intensity, RMDQ, HADS, FAB, PCS, and ISI scores than asymptomatic controls (p < 0.05). The former also had significantly smaller percent thickness changes of LMM at L4/L5 during contraction. LBP-intensity was positively related to scores of PCS-total, PCS-helplessness, FAB-total, FAB-work, and ISI in people with CLBP (p < 0.05). RMDQ scores were positively associated with the scores of HADS-total, HADS-depression, PCS-total, FAB-total, FAB-physical activity, PCS-helplessness, and ISI in people with CLBP (p < 0.05). FAB-work and ISI scores together explained 24% of LBP-intensity. FAB-total scores alone explained 34% of variance of LBP-related disability in people with CLBP.

CONCLUSION

More fear-avoidance belief or insomnia is related to greater LBP-intensity and/or LBP-related disability in people with CLBP. Although people with CLBP were thought to have aberrant LMM morphometry/function, no LMM characteristics were related to LBP-intensity or LBP-related disability after considering other confounders.

The Moderating Effect of Treatment Engagement on Fear-avoidance Beliefs in People With Chronic Low Back Pain

OBJECTIVES

The fear-avoidance model (FAM) is used to explain pain-related disability and design targeted interventions for people with chronic low back pain. While treatment engagement is critical, it is unknown how treatment moderates the FAM.

METHODS

This study examined whether pathways within the FAM were moderated by treatment engagement in 508 people with chronic low back pain. Measures of disability, pain, fear, catastrophizing, anxiety, depression, and self-efficacy were collected through self-report, and descriptors of treatment engaged within the last month (physical activity type, medication, allied and medical health practitioner). Moderated mediation analyses were performed to examine the conditional effect of treatment engagement on fear-avoidance pathways.

RESULTS

The conditional effect of anxiety on disability was only significant for people who did not report any treatment engagement in the last month (B=1.03, 95% confidence interval: 0.53-1.53, P<0.001). The effect of depression increased for people reporting more different types of treatment in the last month (1 level of treatment increase, B=0.27, 95% confidence interval: 0.05-0.50, P=0.019). Conversely, greater treatment engagement had a positive influence on the mediating effect of self-efficacy. That is, the effect of pain on efficacy reduced with greater treatment engagement, with a concomitant increased effect of self-efficacy on disability.

DISCUSSION

Clinicians should explore the history and rationale behind patient treatment seeking behavior to ensure this is not reinforcing the negative effects of depressive symptoms on pain-related disability.

The role of self-efficacy and catastrophizing in explaining improvements in disability, pain and fatigue among patients with chronic widespread pain treated with physiotherapy: an exploratory analysis

OBJECTIVES

Most research exploring the relationship between cognitive factors (catastrophizing and self-efficacy beliefs) and levels of pain, disability and fatigue in patients with chronic widespread pain has been performed in multidisciplinary environments. It is less clear whether these associations are valid in other clinical environments. This study therefore aimed to establish whether changes in cognitive factors were related to changes in pain, disability and fatigue among patients treated in a physiotherapy-led symptom management programme.

DESIGN

A longitudinal pre-post treatment study. Regression analyses were performed with change in pain, disability, physical and mental fatigue as the dependent measures. Demographics, change in pain and fatigue (when not dependent variables) and cognitive factors were entered as independent variables. β values were calculated for the final model.

SETTING

Two out-patient physiotherapy departments in Manchester, UK.

PARTICIPANTS

Fifty patients with persistent widespread pain.

INTERVENTION

A physiotherapist-led symptom management programme.

MAIN OUTCOME MEASURES

Disability (Fibromyalgia Impact Questionnaire), Pain (Numeric Pain Rating Scale and Fatigue (Chalder Fatigue Scale) RESULTS: Significant changes in disability, fatigue and cognitive factors were observed after treatment. Changes in self-efficacy beliefs (β=-0.38, P<0.05) and catastrophizing (β=0.41, P<0.05) were significantly related to reductions in disability. There was no significant relationship between change in the cognitive variables and change in pain or fatigue.

CONCLUSIONS

Self-efficacy beliefs and catastrophizing were important determinants of change in disability, but not pain or fatigue among patients with chronic widespread pain attending physiotherapy. Cognitively-informed physiotherapy appeared to be effective in reducing disability and fatigue and modifying cognitive factors. Such interventions may offer an effective treatment option for patients with chronic widespread pain and future randomised controlled trials are required to fully assess this.

The Role of Fear-Avoidance Beliefs on Low Back Pain-Related Disability in a Developing Socioeconomic and Conservative Culture: A Cross-Sectional Study of a Pakistani Population

Background

The relationship of low back pain, the world’s top disabling condition, with functional disability is often explained by the mediation effect of fear, catastrophizing, and psychological distress. These relationships have not been explored within chronic back pain patients from a low socio-economic, predominantly Muslim country. Thus, it was unclear whether previously established pathways would be consistent in Pakistani pain patients to help guide Pakistani clinicians caring for back pain patients. This cross-sectional study translated English versions of questionnaires within the fear-avoidance model into Urdu, tested the clinimetric properties of the Urdu versions for people with chronic low back pain (CLBP) in Pakistan, and performed mediation analysis to investigate pathways of the fear-avoidance model.

Methods

Translation of questionnaires was completed in 4 steps using the forward-backward technique, with subsequent analyses for internal consistency (Cronbach’s α), construct validity (Pearson’s r-value), and test–retest reliability (ICC r-value). Multiple mediation analysis with bootstrapping was performed to analyze pathways within the fear-avoidance model from the Urdu translated questionnaires.

Results

A total of 151 people from Pakistan with CLBP completed the questionnaires, with good results for internal consistency (r > 0.85), convergent validity (r > 0.59), and test–retest reliability (ICC r > 0.85). The association of pain with disability was significant (B=2.36, r² = 0.19, p<0.001), and the indirect effect of the mediators explained 81% of pain intensity’s total effect on disability. All mediators, apart from physical activity-related fear-avoidance beliefs, were significant mediators of the effect of pain intensity on disability.

Conclusion

The Urdu versions of the fear-avoidance questionnaires show good clinimetric properties for use in clinical settings and research in Pakistan. These analyses support existing data for the mediation effect of catastrophizing, psychological distress, and self-efficacy on pain-related disability, and extends these findings to suggest that fear about work may be more important in a relatively lower socioeconomic sample of pain patients.

Different types of low back pain in relation to pre- and post-natal maternal depressive symptoms

Background

Low back pain (LBP) is a common musculoskeletal problem during pregnancy, with an estimated prevalence ranging from 30–78% (Mota MJ et al. J Back Musculoskelet Rehabil 28(2):351-7,2015 and Abebe E et al. J Med Sc Tech 3(3). 37-44,2014). Women reporting LBP are at increased risk of developing perinatal depression. Pregnancy-related LBP is highly heterogeneous and can be divided into lumbar pain (LP), posterior pelvic pain (PPP), and combined pain (CP). Therefore, the purpose of this study was to investigate the associations between LBP and perinatal depressive symptoms.

Methods

This was a retrospective case-control study conducted from January 2016 to April 2019. A total of 484 pregnant women were enrolled in this study: a case group of 242 pregnant women who were diagnosed with LBP and an age-matched control group of 242 pregnant women without LBP. The Edinburgh Postnatal Depression Scale (EPDS), LBP characteristics, and questionnaires about pregnancy that included demographic, parity, work, comorbidity, and previous pregnancy data were completed and compared between the case group and the control group.

Results

A total of 68 of 242 (28.1%) women experienced PPP, 142 (58.7%) had lumbar pain(LP), and 32 (13.2%) had combined pain. Furthermore, 26.5% of women with prenatal depression in the LP subgroup remained depressed 6 months postnatally, while the percentages for women in the PPP subgroup and CP subgroup were just 10.6% and 15.6%, respectively. The percentage of women who recovered anytime between delivery and six months postnatally in the PPP subgroup was significantly higher than that in the LP subgroup (31.7% vs. 14.7%, P < 0.001).

Conclusions

There is a difference in the prevalence of prenatal, postnatal, and perinatal depressive symptoms among pregnant women with different types of LBP. It is necessary to screen prenatal and postnatal depression separately and differentiate the types of LBP during pregnancy. Attention to these factors may help to outline better management strategies to improve maternal health.

Evaluation of the efficacy of an internet-based pain education and exercise program for chronic musculoskeletal pain in comparison with online self-management booklet: a protocol of a randomised controlled trial with assessor-blinded, 12-month follow-up, and economic evaluation

BACKGROUND

Chronic musculoskeletal pain is one of the main causes of years lived with disability and generates the highest cost of health care among chronic pain conditions. Internet-based treatments have been shown to be an alternative for the treatment of musculoskeletal conditions, in addition to reducing barriers such as travel, high demands on the public health system, lack of time, lack of insurance coverage for private care, and high costs for long-term treatment. The aim of this clinical trial is to develop and test the effectiveness and cost-effectiveness of, an internet-based self-management program based on pain education and exercise for people with chronic musculoskeletal pain.

METHODS

This is a prospectively registered, assessor-blinded, two-arm randomised controlled trial with economic evaluation comparing the Internet-based pain education and exercise intervention with a control group that will receive an online booklet. One hundred and sixty patients will be recruited from Sao Paulo, Brazil. Follow-ups will be conducted in post-treatment, 6 and 12 months after randomisation. The conduct of the study, as well as the evaluations and follow-ups will be carried out entirely remotely, through online platforms and telephone calls. The primary outcome will be pain intensity at post-treatment (8 weeks) measured using the 11-item Pain Numerical Rating Scale. Secondary outcomes will be biopsychosocial factors presents in the chronic musculoskeletal pain condition. Costs due to chronic musculoskeletal pain will be also measured, and cost-effectiveness analysis from a societal perspective will performed.

DISCUSSION

Our hypothesis is that internet-based pain education and exercise will be better than an online booklet in reducing pain and improving biopsychosocial outcomes in patients with chronic musculoskeletal pain. In addition, we believe that there will be good acceptance of patients for the internet-based intervention and that internet-based intervention will be more cost effective than the online booklet.

TRIAL REGISTRATION

The study was prospectively registered at ClinicalTrials.gov ( NCT04274439 , registered 18 February 2020).

Does the awareness of having a lumbar spondylolisthesis influence self-efficacy and kinesiophobia? A retrospective analysis

Background

High pain self-efficacy and low kinesiophobia seem related to a better prognosis in patients complaining of low back pain (LBP). The literature stresses the potential negative effects of anatomical defect diagnosis (e.g. lumbar spondylolisthesis) on the psychological profile. The aim of this study is to investigate the relationships between awareness of having a spondylolisthesis, pain self-efficacy and kinesiophobia.

Methods

A secondary retrospective analysis was done. Ninety-eight subjects with subacute and chronic LBP were included: 49 subjects with diagnosed symptomatic lumbar spondylolisthesis and 49 subjects with diagnosed non-specific LBP. The pain self-efficacy measured with the Pain Self-Efficacy Questionnaire and the fear of movement measured with the Tampa Scale of Kinesiophobia were considered variables to investigate, whereas diagnosis and demographic/clinical variables were considered predictors or potential confounders.

Results

By comparing the two groups, the awareness of having a spondylolisthesis did not significantly influence neither pain self-efficacy (p = 0.82), nor kinesiophobia (p = 0.75). Higher perceived pain reduces pain self-efficacy and increases kinesiophobia in both groups (p = 0.002 and p = 0,031 respectively).

Conclusions

It seems that the awareness of an anatomical defect as spondylolisthesis does not significantly affect the beliefs of carry out activities and movements despite the pain. Other studies with wider samples are required, to confirm these preliminary results.

The relationship of illness perceptions with demographic features, pain severity, functional capacity, disability, depression, and quality of life in patients with chronic low back pain

Objectives

The aim of this study was to evaluate the relationship of illness perceptions (IPs) with demographic features, severity of pain, functional capacity, disability, depression, and quality of life in patients with chronic low back pain (CLBP).

Patients and methods

Between January 2015 and July 2015, a total of 114 patients with non-specific CLBP (86 females, 28 males; mean age 47.1±15.2 years; range, 18 to 85 years) were included. Non-specific CLBP was defined as low back pain not attributable to a recognizable, known specific pathology such as infection, tumor, inflammation for ≥12 weeks. The IPs using the revised Illness Perception Questionnaire (IPQ-R), pain severity using the visual analog scale (VAS), functional capacity using the Six-Minute Walk Test (6MWT), disability using the modified Oswestry Disability Index (m-ODI), depression using the Beck Depression Inventory (BDI), and quality of life using the Short Form-36 (SF-36) were assessed.

Results

There was a significant, positive correlation between the age, body mass index, duration of disease, pain scores, and IPQ-R- consequences, timeline (acute/chronic), and emotional responses subunits, whereas there was a significant, negative correlation between the IPQ-R-personal and treatment control subunits (p<0.001). The IPQ-R-timeline (acute/chronic), consequences, and emotional response subunits were positively and personal and treatment controls and illness coherence subunits were negatively correlated with the BDI and m-ODI (p<0.001). The IPQ-R-consequences and emotional responses subunits were negatively and timeline (acute/chronic), personal and treatment controls, and illness coherence subunits were positively correlated with the SF-36 subunits (p<0.05).

Conclusion

The IPs were negatively affected by advanced age, high body mass index, longer duration of disease, and increased severity of pain in CLBP patients. Based on these findings, positive IPs may be related with reduced disability and depression, and improved quality of life and functional capacity in this patient population. Developing new strategies for improving the negative IPs of patients with CLBP may be useful.

Smoking is associated with greater pain intensity and pain-related occupational disability in Japanese workers

PURPOSE

Pain symptom, such as that caused by musculoskeletal disorders, is a major cause of occupational disability. As nicotine intake from smoking increases pain sensitivity, smokers may experience stronger pain and be more likely to experience pain-related disability than non-smokers. The study aim was to examine whether smoking was associated with pain-related occupational disability via pain intensity.

METHODS

Participants were 1189 workers with pain aged 20-74 years in Japan. Participants completed a self-report questionnaire, which included a question to measure pain-related occupational disability with ordinal-option: (1) without pain-related disability, (2) pain-related presenteeism, and (3) pain-related absenteeism. An ordinal logistic regression model was used to calculate multivariable-adjusted proportional odds ratios (OR) with 95% confidence intervals (CI) for the prevalence of pain-related occupational disability according to smoking status. A multiple mediation analysis was also conducted to assess whether pain sensitivity mediated the association between smoking and pain-related occupational disability. Adjusted variables were demographic variables, socioeconomic status, work-related psychosocial factors, general psychological factors, and pain duration.

RESULTS

Current smoking and pain were associated with pain-related occupational disability compared with non-smoking and pain (multivariable OR 1.78; 95% CI 1.26-2.52). Greater pain intensity partially mediated the association of current smoking and pain with pain-related occupational disability. The mediation rate (indirect/total effect) was 25%.

CONCLUSION

Smoking and pain were associated with pain-related occupational disability, partially through greater pain intensity, among Japanese workers.

Physiotherapy Based on a Biobehavioral Approach with or Without Orthopedic Manual Physical Therapy in the Treatment of Nonspecific Chronic Low Back Pain: A Randomized Controlled Trial

Objective

To compare the effectiveness of a biobehavioral approach with and without orthopedic manual physical therapy on the intensity and frequency of pain in patients diagnosed with nonspecific chronic low back pain.

Methods

A single-blind randomized controlled trial. Fifty patients were randomly allocated into two groups: one group received biobehavioral therapy with orthopedic manual physical therapy, and the other group received only biobehavioral therapy. Both groups completed a total of eight sessions, with a frequency of two sessions per week. The somatosensory, physical, and psychological variables were recorded at baseline and during the first and third month after initiation of treatment.

Results

In both groups, the treatment was effective, presenting significant differences for all the variables in the time factor. There were no significant differences between groups in intensity or frequency of pain, with a large effect size (&gt;0.80), but there were intragroup differences for both intervention groups at one- and three-month follow-up. There were also no significant differences between groups in the secondary variables during the same follow-up period.

Conclusions

The results of this study suggest that orthopedic manual physical therapy does not increase the effects of a treatment based on biobehavioral therapy in the short or medium term, but these results should be interpreted with caution.

Cognitive factors are associated with disability and pain, but not fatigue among physiotherapy attendees with persistent pain and fatigue

OBJECTIVES

Most research exploring the relationship between cognitive factors and pain, disability and fatigue in patients with persistent pain/fatigue has been performed in multi disciplinary environments. It is unclear whether these associations are consistent in other contexts. This study therefore aimed to establish the relationships between these factors in patients with persistent pain/fatigue referred for physiotherapy treatment.

DESIGN

Cross-sectional observational study assessing the association between cognitive factors (self-efficacy and catastrophizing) and levels of pain, disability, mental fatigue and physical fatigue in patients with persistent pain/fatigue disorders. Data were analysed using regression analyses.

SETTING

Two out-patient physiotherapy departments, Manchester, UK.

PARTICIPANTS

166 patients with persistent pain and fatigue disorders chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalopathy).

MAIN OUTCOME MEASURES

Disability was assessed using the Fibromyalgia Impact Questionnaire, whilst mental and physical fatigue were assessed with the sub-scales of the Chalder Fatigue Scale. Pain intensity was measured with a Numeric Pain Rating Scale, self-efficacy with the Chronic Pain Self-efficacy Questionnaire and catastrophizing with the Pain Catastrophizing Scale.

RESULTS

Cognitive factors were significantly associated with pain (self-efficacy beliefs β=-0.30, P<0.05; catastrophizing β=0.24, P<0.05) and disability (self-efficacy beliefs β=-0.62, P<0.05), but not fatigue.

CONCLUSIONS

Similar associations were observed in patients referred to physiotherapy as to those observed in patients treated in multi disciplinary clinical environments. Self-efficacy beliefs appear to be particularly strong determinants of disability, but exert a lesser influence over pain or fatigue. Targeting self-efficacy may be an effective method to reduce disability in patients with persistent pain and fatigue disorders.

Are changes in pain, cognitive appraisals and coping strategies associated with changes in physical functioning in older adults with joint pain and chronic diseases?

BACKGROUND

As the population ages, the number of people with chronic diseases increases. Frequently, older people suffer from joint pain together with other chronic diseases, which can lead to decreased physical functioning.

AIMS

To investigate the associations of the changes in cognitive appraisals, coping strategies and pain with the change in physical functioning in older people, who have chronic pain and chronic diseases.

METHODS

Elderly persons (n = 407, mean age 77 years, and 62% female), with self-reported joint pain and at least two chronic diseases, filled in questionnaires about cognitive appraisals, coping strategies, pain intensity and physical functioning at baseline, at 6- and 18-month follow-ups. The associations of change in physical functioning with changes in cognitive appraisals, coping strategies and pain were modelled using generalized estimating equations (GEE).

RESULTS

Increase in pain, in negative thinking about the consequences of pain, and in activity avoidance and decrease in self-efficacy beliefs were associated with a decline in physical functioning.

DISCUSSION

Observed mean changes were small but large inter-individual variability was seen. This shows that cognitive appraisals and coping strategies are malleable. Statistical model of change clarifies the direction of longitudinal associations.

CONCLUSIONS

The longitudinal findings suggest that joint pain, cognitive appraisals and coping strategies may determine physical functioning in older people who have chronic pain and comorbidity.

Improvements in health-related quality of life and function in middle-aged women with chronic diseases of lifestyle after participating in a non-pharmacological intervention programme: A pragmatic randomised controlled trial

Background

Musculoskeletal diseases consume a large amount of health and social resources and are a major cause of disability in both low- and high-income countries. In addition, patients frequently present with co-morbid chronic diseases of lifestyle. The area of musculoskeletal disease is restricted by a lack of epidemiological knowledge, particularly in low- and middle-income countries.

Objectives

This pragmatic randomised controlled trial assessed the benefits of a 6-week physiotherapy intervention for middle-aged women with musculoskeletal conditions compared to usual care.

Method

A weekly 2-h educational programme utilising a workbook, discussion group and exercise class was presented for the intervention group, while the control group received usual care. The primary outcome was health-related quality of life. Parametric and non-parametric data were used to determine the equivalence between the groups.

Results

Twenty-two participants were randomised to the intervention and 20 to the control group. The control group demonstrated no within-group improvement in health-related quality of life items, compared to significant improvements in two items in the intervention group. The change in median utility score within the intervention group was twice as large as the change in the control group. With regard to self-efficacy, the intervention group demonstrated significant within-group changes in perceived management of fatigue and discomfort.

Conclusion

The positive impact of the intervention on the participants suggests that the programme should continue at the clinic in question, but should be presented at a more convenient time for participants who work, as recruitment to the study was less than anticipated. Primary health care systems in South Africa urgently need to put structures in place for effective management of the functional impact of chronic diseases of lifestyle and musculoskeletal conditions. It is time for physiotherapists and possibly other health care professionals to participate in the development of appropriate community level interventions to address the functioning and quality of life of individuals living with the diseases.

Disability and health outcomes - from a cohort of people on long-term anti-retroviral therapy

Human-immunodeficiency virus (HIV)/Acquired immunodeficiency Syndrome (AIDS) remains a major health problem in South Africa - even after two decades since the introduction of antiretroviral therapy (ART). Long-term survival with HIV is associated with new health-related issues and a risk of functional limitation/disability. The aim of this study was to assess functional limitation associated with HIV/AIDS among people living with HIV (PLHIV) in South Africa. This study is a cross-sectional survey using a cohort in an urban area in Gauteng province, South Africa. Data were collected using questionnaires through an interview process. The information collected included aspects such as demographics, livelihood, the state of mental and physical health, adherence and disability. A total of 1044 participants with an average age of 42 ± 12 years were included in the study, with 51.9% of the participants reporting functional limitations (WHODAS ≥ 2). These were reported mainly in the domains of participation (40.2%) and mobility (38.7%). In addition, adherence to ART, symptoms of poor physical health and depression were strongly associated with their functional limitations/disability. HIV as a chronic disease is associated with functional limitations that are not adequately addressed and pose a risk of long-term disability and negative adherence outcomes. Therefore, wellness for PLHIV/AIDS needs to include interventions that can prevent and manage disability.

Patients with severe low back pain exhibit a low level of physical activity before lumbar fusion surgery: a cross-sectional study

BACKGROUND

People with severe low back pain are at higher risk of poor health. Patients scheduled for lumbar fusion surgery are assumed to have low levels of physical activity, but few data exist. The aim of the study was firstly to investigate preoperative levels of objectively measured physical activity in patients with severe low back pain waiting for lumbar fusion surgery, and secondly to investigate whether factors in the fear-avoidance model were associated with these levels.

METHODS

We included 118 patients waiting for lumbar fusion surgery (63 women and 55 men; mean age 46 years). Physical activity expressed as steps per day and total time spent in at least moderate-intensity physical activity was assessed with ActiGraph GT3X+ accelerometers. The data were compared to the WHO recommendations on physical activity for health. Whether factors in the fear-avoidance model were associated with physical activity was evaluated by two different multiple linear regression models.

RESULTS

Ninety-six patients (83%) did not reach the WHO recommendations on physical activity for health, and 19 (16%) patients took fewer than 5000 steps per day, which indicates a sedentary lifestyle. On a group level, higher scores for fear of movement and disability were associated with lower numbers of steps per day.

CONCLUSION

A high proportion of the patients did not reach the WHO recommendations on physical activity and are therefore at risk of poor health due to insufficient physical activity. We also found a negative association between both fear of movement and disability, and the number of steps per day. Action needs to be taken to motivate patients to be more physically active before surgery, to improve health postoperatively. There is a need for interventions aimed at increasing physical activity levels and reducing barriers to physical activity in the prehabilitation phase of this patient group.

TRIAL REGISTRATION

Current Controlled Trials ISCRTN 17115599 , retrospectively Registered 18 may 2015.

Health professionals' referral practice and related healthcare utilization for people with low back pain in Singapore: A retrospective study

Background

Low back pain is a common musculoskeletal disorder that can incur high financial burden. A significant proportion of this burden may be incurred from referrals to health services and subsequent healthcare usages. Patients' overall experience of pain and its related life interferences may also have some relevance to this usage.

Objective

This study aimed to examine the referral practices and subsequent health service utilization of patients with LBP within a tertiary specialist clinic setting. A secondary objective was to explore potential associations between primary independent variables of pain and life interferences with health service utilization.

Methods

Participants were patients with low back pain, who completed a set of self-reported low back pain measures. These included measures for pain intensity, pain interference, disability and quality of life. The participants' back pain-related referral and health service utilization in the subsequent 12 months were recorded.

Results

A total of 282 patients completed the full measures. Of these, 59.9% were referred for physiotherapy, 26.3% for diagnostic imaging and 9.2% for interventional procedures. Compared to patients who were referred from tertiary care, those from primary care had lower pain intensity ( p = 0 . 001 ), pain interference ( p = 0 . 002 ), disability ( p = 0 . 001 ), but better physical and mental quality of life ( p < 0 . 001 , p = 0 . 017 ). High pain interference was a common factor among patients who were referred on to other services after first consultation. Levels of medical utilization and physiotherapy utilization were both associated with pain intensity ( F = 2 . 39 , p = 0 . 027 vs F = 3 . 87 , p = 0 . 001 ), pain interference ( F = 5 . 56 , p = 0 . 007 vs F = 4 . 12 , 0.01) and disability ( F = 5 . 89 , p = 0 . 001 vs F = 3 . 40 , p = 0 . 016 ). Regression analysis showed that the source of referral contributed to 6% of the variance in medical utilization and 3% of the variance in physiotherapy utilization. After controlling the demographic variables and referral sources, none of the independent variables added any significant variance to medical utilization. Only pain intensity contributed an additional 2% variance to physiotherapy utilization.

Conclusion

Referral patterns and practices appear similar to those reported in other studies. Higher levels of pain intensity, interference, disability and quality of life appear to influence the referral to different health services and subsequent treatment utilization.

The comorbidity of low back pelvic pain and risk of depression and anxiety in pregnancy in primiparous women

Background

Approximately 50% of Australian women experience low back pain in pregnancy, with somewhere between 8 and 36% of women suffering from pregnancy related depression/anxiety. Both low back and pelvic pain and depression and anxiety are associated with poor maternal health outcomes, including increased sick leave, higher rates of functional disability, and increased access to healthcare. It also impacts upon time and mode of delivery with an increase in inductions and elective caesarean sections. For babies of women with depression and anxiety preterm birth, low birth weight and intrauterine growth restriction are all common complications. Given these poor health outcomes, it is important to determine the co-morbidity of low back and pelvic pain and depression/anxiety in pregnancy.

Methods

A cross sectional study of a hospital based sample of 96 nulliparous women were assessed at 28 weeks as part of their routine antenatal appointment. Data was collected via interview and clinical records and included the Edinburgh Depression Scale (EDS), the Numerical Rating Scale (NRS) and the Modified Oswestry Low Back Pain Disability Questionnaire (MODQ). Spearman’s correlation co-efficients, prevalence ratios and ANOVA were used to determine comorbidity.

Results

96 women consented to participation in the study. All study outcomes were moderately correlated. There were three main findings: One, there was a positive correlation between low back and pelvic girdle pain (LBPP) and depression/anxiety was rho = 0.39, p < 0.001, between LBPP and functional disability was rho = 0.51, p < 0.001 and between risk of depression/anxiety and functional disability was rho = 0.54, p < 0.001. Two, a woman with LBPP was 13 times more likely to have increased risk of depression/anxiety, whilst a woman with increased risk of depression/anxiety was 2.2 times more likely to have LBPP and finally three, amongst women who reported LBPP, the level of disability experienced was significantly higher in women who had concurrent increased risk of depression/anxiety (p = 0.003). This occurred even though the severity of pain did not differ between groups (NRS score mean p = 0.38).

Conclusions

This study found a high level of co-occurrence of LBPP, functional disability and depression/anxiety in women in their third trimester of pregnancy. Importantly women who reported higher depression/anxiety symptoms appeared to experience higher levels of functional disability in relation to their LBPP, than women with lower depression/anxiety symptoms and LBPP.

Validity and Responsiveness of the Pain Self-Efficacy Questionnaire in Patients With Neck Pain Disorders

Study Design Longitudinal clinimetric study. Background Pain self-efficacy predicts poor recovery and mediates the relationship between pain and disability in patients with neck pain disorders (NPDs). The Pain Self-Efficacy Questionnaire (PSEQ) is a frequently used instrument to measure pain self-efficacy; however, its measurement properties have never been evaluated in a group of patients with NPDs. Objectives This study aimed to assess validity and responsiveness of the PSEQ in patients with NPDs. Methods Patients with NPDs (n = 161) were included. Confirmatory and exploratory factor analysis was used to assess structural validity. Twelve hypotheses on expected correlations with other instruments were formulated a priori to assess construct validity. Responsiveness was evaluated in 146 patients with NPDs who underwent multimodal rehabilitation by testing 12 hypotheses on expected effect sizes, area under the curve, and correlations with change in other instruments. Results Factor analyses showed that the PSEQ is a unidimensional instrument with moderate construct validity and responsiveness (50% to 75% of hypotheses met). Validity was consistent when analyzed separately for patients with whiplash-associated disorders and idiopathic neck pain, and responsiveness was better in patients with idiopathic neck pain. Conclusion The PSEQ is a unidimensional measure of pain self-efficacy in patients with NPDs, as found by previous studies in other populations. Nevertheless, in contrast with previous studies, its construct validity and responsiveness were found to be suboptimal in NPDs, suggesting that the content validity of the PSEQ and of the comparator instruments used in this study should be better assessed. J Orthop Sports Phys Ther 2018;48(3):204-216. Epub 19 Dec 2017. doi:10.2519/jospt.2018.7605.

Does Age Affect the Relationship Between Pain and Disability? A Descriptive Study in Individuals Suffering From Chronic Low Back Pain

BACKGROUND

Previous studies have revealed a weak to moderate relationship between pain and disability in individuals suffering from low back pain (LBP). However, to our knowledge, no studies have evaluated if this relationship is different between young and older adults.

PURPOSE

The objective of this descriptive, cross-sectional study was to determine whether the relationship between LBP intensity and physical disability is different between young and older adults.

METHODS

Pain intensity (measured with a visual analog scale) and physical disability scores (measured with the Oswestry Disability Index) were collected from the medical files of 164 patients with LBP. Separate Pearson correlation coefficients were calculated between these 2 variables for young (mean age 40 ± 6 years, n = 82) and older (62 ± 9 years, n = 82) individuals and a Fisher r-to-z transformation was used to test for group differences in the strength of the relationship. Linear regression analyses were also performed to determine whether the slope of the association was different between the 2 groups.

RESULTS

A significant and positive association was found between pain intensity and disability for both young and older individuals. However, the correlation was stronger in the young group (r = 0.66; P < .01) than in the older group (r = 0.44; P < .01) (Fisher Z = 2.03; P < .05). The linear regression model also revealed that the slope of the relationship was steeper in the young group (P < .05).

CONCLUSION

Although both young and older individuals showed a significant association between pain intensity and disability, the relationship between these 2 variables was more tenuous in older individuals than in young patients. Future research is essential to identify the factors underlying this age-related difference.

The Influence of Self-Efficacy, Fear-Avoidance Belief, and Coping Styles on Quality of Life for Chinese Patients with Chronic Nonspecific Low Back Pain: A Multisite Cross-Sectional Study

BACKGROUND

As a bio-psycho-social issue, chronic low back pain (CLBP) has been a significant topic in health management, and patients' quality of life (QOL) is gaining extensive attention. Self-efficacy, pain fear-avoidance belief (FAB), and coping styles play important roles in the QOL of CLBP patients. However, it remains unclear how self-efficacy and FAB influence QOL through specific coping styles. This study aimed to explore the influencing paths of self-efficacy, FAB, and coping styles on the QOL of patients with CLBP.

METHODS

This study relies on a multisite, cross-sectional design involving 221 CLBP patients. Stepwise multiple regression and structural equation modeling were employed.

RESULTS

CLBP patients lived with a poor global QOL. Self-efficacy played a direct, positive role in predicting QOL for patients with CLBP (β = 0.35), and it also played an indirect, positive role in predicting QOL (β = 0.19) through active coping styles (β = 0.31). FAB played a direct, negative role in predicting QOL (β = -0.33), and it also played an indirect, negative role in predicting QOL (β = -0.32) through passive coping styles (β = 0.32).

CONCLUSIONS

Self-efficacy and FAB are both directly and indirectly related to global QOL, and coping styles are important mediating variables. Self-efficacy and active coping are protective factors for the QOL of CLBP patients, while FAB and passive coping are risk factors. Health education strategies are recommended by medical personnel to enhance CLBP patients' pain self-efficacy, decrease pain FAB, and modify pain coping styles, so that their global QOL can be improved.

Self-efficacy and self-care-related outcomes following Alexander Technique lessons for people with chronic neck pain in the ATLAS randomised, controlled trial

Introduction

ATLAS was a pragmatic randomised (1:1:1 ratio), controlled trial recruiting patients with chronic neck pain (N = 517) and evaluating one-to-one Alexander Technique lessons, or acupuncture, each plus usual care, compared with usual care alone. The primary outcome (12-month Northwick Park Neck Pain Questionnaire [NPQ]) demonstrated significant and clinically meaningful reductions in neck pain and associated disability for both interventions compared with usual care alone. Here we describe pre-specified, self-efficacy and other self-care-related outcomes for the Alexander group compared with usual care.

Methods

Participants reported on 11 self-efficacy/self-care-related outcome measures at 6 and 12 months. Linear or logistic regression models evaluated changes in parameters and impact on NPQ. Alexander teachers reported on lesson content.

Results

Lesson content reflected standard UK practice. The Alexander group (n = 172) reported significantly greater improvements, compared with usual care alone (n = 172), in most of the self-efficacy/self-care measures (9/11 measures at 6 months, and 8/11 at 12 months), including the ability to reduce pain in daily life. At 6 months, 81% (106/131) of Alexander participants reported significant improvement in the way they lived and cared for themselves (versus 23% for usual care), increasing to 87% (117/135) at 12 months (usual care: 25%). NPQ scores at both 6 and 12 months were related to improvement in self-efficacy and ability to reduce pain during daily life.

Conclusions

Alexander Technique lessons led to long-term improvements in the way participants lived their daily lives and managed their neck pain. Alexander lessons promote self-efficacy and self-care, with consequent reductions in chronic neck pain.

Process of Change in Pain-Related Fear: Clinical Insights From a Single Case Report of Persistent Back Pain Managed With Cognitive Functional Therapy

Study Design Single case report with repeated measures over 18 months. Background Management of persistent low back pain (PLBP) associated with high pain-related fear is complex. This case report aims to provide clinicians with insight into the process of change in a person with PLBP and high bending-related fear, who was managed with an individualized behavioral approach of cognitive functional therapy. Case Description A retired manual worker with PLBP believed that his spine was degenerating, that bending would hurt him, and that avoidance was the only form of pain control. At baseline, he presented high levels of pain-related fear on the Tampa Scale of Kinesiophobia (score, 47/68) and a high-risk profile on the Örebro Musculoskeletal Pain Questionnaire (score, 61/100). Unhelpful beliefs and behaviors led to a vicious cycle of fear and disengagement from valued life activities. Guided behavioral experiments were used to challenge his thoughts and protective responses, indicating that his behavior was modifiable and the pain controllable. Using a multidimensional clinical-reasoning framework, cognitive functional therapy management was tailored to target key drivers of PLBP and delivered over 6 sessions in a 3-month period. Outcomes Over an 18-month clinical journey, he demonstrated improvements in bending-related fear, pain expectancy, and pain experience, and substantial changes in pain-related fear (Tampa Scale of Kinesiophobia: 33/68; change, -14 points) and risk profile (Örebro Musculoskeletal Pain Questionnaire: 36/100; change, -25 points). Clinical interviews at 6 and 18 months revealed positive changes in mindset, understanding of pain, perceived pain control, and behavioral responses to pain. Discussion This case report provides clinicians with an insight to using a multidimensional clinical-reasoning framework to identify and target the key drivers of the disorder, and to using cognitive functional therapy to address unhelpful psychological and behavioral responses to pain in a person with PLBP and high pain-related fear. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2017;47(9):637-651. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7371.

Are fear of movement, self-efficacy beliefs and fear of falling associated with levels of disability in people with osteoarthritis of the knee? A cross sectional study

INTRODUCTION

Osteoarthritis of the knee (OAK) can result in significant disability and previous authors have suggested that cognitive and falls-related factors may be significant determinants of function. However, no previous studies have considered the relative influence of these factors when the effects of symptoms related to OAK are also considered. Additionally, it is plausible that falls-related factors exert a greater influence in patients who have previously fallen.

METHODS

Fifty-eight patients were recruited from an outpatient physiotherapy department. They completed measures of physical function, pain, stiffness, physical symptoms, fear avoidance, perceived consequences of falling, fear of falling and self-efficacy beliefs. Variables exhibiting significant correlations with disability were entered into a regression model. β Values were also calculated for the final model to allow the relative contribution of each variable to be established when all variables were considered. Sub-analysis was then performed using only data from patients who had previously fallen, to establish whether cognitive and falls-related factors exerted a stronger influence in this group.

RESULTS

Pain, stiffness and joint symptoms significantly explained 75% of the variance in disability. The cognitive and falls-related variables did not significantly explain any additional variance. Only pain and stiffness exhibited significant β values in the final model. Similar findings were observed in the sub-analysis with the participants who had previously fallen, with only pain and stiffness explaining significant variance (77%) or exhibiting significant β values.

DISCUSSION

The current findings suggested that cognitive and falls-related factors are not significantly related to disability in patients with OAK. By contrast, pain and stiffness were strongly associated with disability. This suggests that targeting cognitive and falls-related factors is unlikely significantly to improve outcome in these patients.

Potential analysis of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain / Potentialanalyse der multidisziplinären biopsychosozialen Rehabilitation für Patienten/-innen mit chronischen Rückenschmerzen

Health problem

The prevalence of low back pain ranges from 74 to 85%, almost everybody in Germany suffers from low back pain once in his or her life. The recurrence rate within twelve months is 62%, which often leads to inability to work and reduction in earning capacity. The rate of chronic manifestation of low back pain is 5%. Subsequent loss of mobility and functional disability lowers quality of life and participation in private life and at work.

Evidence

A recent Cochrane review (Kamper et al., 2014) analysed six (outcome disability) and seven (outcome pain) studies with 722 and 821 participants respectively and showed that multidisciplinary rehabilitation compared to usual care has a small, but clinically relevant effect (pain: SMD -0,21 [CI 95% -0,37; -0,04]; disability: SMD -0,23 [CI 95% -0,4; -0,06]). There is a lack of evidence about the intervention conception, patient-centred outcomes and the cost effectiveness.

Implication for research

Prior to a randomised controlled trial a feasibility study about individualised multidisciplinary biopsychosocial rehabilitation compared to usual care considering people with chronic low back pain at employable age in Germany is needed. The applicability of available manuals, patient-centred outcomes and cost effectiveness should be explored.

Passion for leisure activity contributes to pain experiences during rehabilitation

The primary aim of this study was to determine whether the levels of obsessive passion (OP) and harmonious passion for a suspended leisure activity contribute to pain catastrophizing and pain intensity in patients undergoing the rehabilitation process. The secondary aim was to examine whether the levels of passion associated with a maintained leisure activity offset the contribution of having a leisure activity suspended to pain intensity and catastrophizing. Ninety-one outpatients from functional rehabilitation units (Mage=37, SD=13.44 years) completed measures of pain catastrophizing, pain intensity, and passion about valued leisure activities (one they were prevented from practicing and one they remained able to practice). Correlation analysis showed that the level of OP for a suspended valued leisure activity was positively associated with pain catastrophizing and pain intensity. Results showed that pain catastrophizing mediated the relationship between this level of passion and pain intensity. The levels of harmonious passion and OP for a maintained valued leisure activity did not offset the contribution of OP for a suspended leisure activity to pain-related outcomes. When prevented from practicing a valued leisure activity, only OP contributes to the prediction of pain catastrophizing and pain intensity. The contribution of pain catastrophizing provides a potential explanation for why the level of OP for a suspended leisure activity is related to pain intensity ratings. The benefits of maintaining a valued leisure activity during rehabilitation do not seem sufficient to counterbalance the maladaptive effects of being prevented from the practice of a previous/another valued leisure activity.

The processes underpinning reductions in disability among people with chronic neck pain. A preliminary comparison between two distinct types of physiotherapy intervention

PURPOSE

To establish whether different processes underpin changes in disability in people with neck pain who underwent two types of active physiotherapy intervention.

MATERIALS AND METHODS

This study was a sub-analysis of a randomized controlled trial assessing whether the addition of Interactive Behavioral Modification Therapy (a cognitively informed physiotherapy treatment) to a Progressive Neck Exercise Program improved outcome in patients with chronic neck pain. Regression analyses were performed to determine the extent to which demographics, changes in pain, and changes in certain cognitive factors were related to changes in disability.

RESULTS

In the progressive neck exercise group, changes in levels of pain intensity were the only factor significantly related to change in disability, explaining 33% of the variance. In the interactive behavioral modification therapy group, changes in pain intensity, and catastrophizing together explained 54% of the variance in change in disability. Only changes in catastrophizing displayed a significant β value in the final model.

CONCLUSIONS

Different processes appear to underpin changes in disability in patients undergoing cognitively informed physiotherapy to those undergoing a primarily exercise-based approach. Implications for rehabilitation Certain cognitive factors are known to be related to levels of disability in patients with chronic neck pain Specifically targeting these factors results in more patients making a clinically meaningful reduction in disability Different processes appear to underpin reductions in disability when people with neck pain are treated with cognitively informed physiotherapy to when treated with exercise alone, which may account for why more patients improve when treated in this manner. Reductions in catastrophizing appear to be particularly important and efforts should be made to assess and treat catastrophic thoughts in people with chronic neck pain.

The Relation between the Fear-Avoidance Model and Constructs from the Social Cognitive Theory in Acute WAD

In the fear-avoidance (FA) model social cognitive constructs could add to explaining the disabling process in whiplash associated disorder (WAD). The aim was to exemplify the possible input from Social Cognitive Theory on the FA model. Specifically the role of functional self-efficacy and perceived responses from a spouse/intimate partner was studied. A cross-sectional and correlational design was used. Data from 64 patients with acute WAD were used. Measures were pain intensity measured with a numerical rating scale, the Pain Disability Index, support, punishing responses, solicitous responses, and distracting responses subscales from the Multidimensional Pain Inventory, the Catastrophizing subscale from the Coping Strategies Questionnaire, the Tampa Scale of Kinesiophobia, and the Self-Efficacy Scale. Bivariate correlational, simple linear regression, and multiple regression analyses were used. In the statistical prediction models high pain intensity indicated high punishing responses, which indicated high catastrophizing. High catastrophizing indicated high fear of movement, which indicated low self-efficacy. Low self-efficacy indicated high disability, which indicated high pain intensity. All independent variables together explained 66.4% of the variance in pain disability, p < 0.001. Results suggest a possible link between one aspect of the social environment, perceived punishing responses from a spouse/intimate partner, pain intensity, and catastrophizing. Further, results support a mediating role of self-efficacy between fear of movement and disability in WAD.

Can physical therapy centred on cognitive and behavioural principles improve pain self-efficacy in symptomatic lumbar isthmic spondylolisthesis? A case series

PURPOSE

Pain-related self-efficacy is defined as "the beliefs held by people with chronic pain that were able to carry out certain activities, even when experiencing pain", and it is considered a relevant mediator in the relationship between pain and disability in chronic low back pain. This case series describes a treatment aiming to improve pain self-efficacy in patients with symptomatic lumbar spondylolisthesis.

METHOD

Ten consecutive outpatients with lumbar spondylolisthesis and chronic LBP referred to a rehabilitative clinic participated in this study. Cognitive and behavioural principles were integrated with functional and graded approach in each individual physical therapy program. The outcome measures concerned clinical instability and endurance tests, pain, disability and self-efficacy.

RESULTS

Pain self-efficacy and lumbar function improved in 7 out of 10 patients; clinical tests improved in 9 out of 10 patients.

CONCLUSION

A rehabilitation program carried out by a physical therapist, centred on cognitive and behavioural principles, appeared useful in improving pain self-efficacy and lumbar function. These results may be interesting for future controlled trials.

The relationship between knowledge of pain neurophysiology and fear avoidance in people with chronic pain: A point in time, observational study

Chronic pain is prevalent in the western world; however fear of pain often has a greater impact than the degree of initial injury. The aim of this study was to explore the relationship between knowledge of the neurophysiology of pain and fear avoidance in individuals diagnosed with chronic pain. Twenty-nine people with chronic musculoskeletal pain were recruited and completed questionnaires to determine their understanding of pain neurophysiology and the degree of their fear avoidance beliefs. There was an inverse relationship between knowledge of pain neurophysiology and the level of fear avoidance. Patients with higher pain knowledge reported less fear avoidance and lower perceived disability due to pain. There was no relationship with the educational level or compensable status for either variable. The findings suggest that fear avoidance is positively influenced by neurophysiology of pain education, so that a higher level of pain knowledge is associated with less activity-related fear. The clinical implication is that reducing fear avoidance/kinesiophobia using neurophysiology of pain education in people with chronic pain may provide an effective strategy to help manage fear avoidance and related disability in the chronic pain population in order to improve treatment outcomes.

Psychiatric and psychological perspectives on chronic pain

Chronic pain patients often have psychiatric disorders that negatively influence their responses to treatment. Also, many of them have dysfunctional beliefs and coping strategies, even if they do not meet DSM-5 criteria for a psychiatric disorder. Physiatrists should have a low threshold for referring both groups of patients for mental health services. This article describes psychiatric disorders that are highly prevalent among pain patients and also describes psychological processes that contribute to poor coping by the patients. Finally, it discusses factors that a physiatrist should consider in deciding whether to refer patients to psychiatrists versus psychologists.

Responsiveness and Minimal Important Change of the Pain Self-Efficacy Questionnaire and Short Forms in Patients With Chronic Low Back Pain

The Pain Self-Efficacy Questionnaire (PSEQ) is a valid and reliable patient-reported instrument used to assess pain self-efficacy in patients with chronic low back pain (CLBP). Recently, the 2-item (PSEQ-2) and the 4-item (PSEQ-4) short versions were developed showing satisfactory measurement properties in mixed populations with chronic pain. The aim of this study was to examine responsiveness and minimal important change (MIC) of PSEQ, PSEQ-2, and PSEQ-4 in patients with CLBP. We used a sample of 104 patients undergoing multimodal physical therapy designed to partly change pain self-efficacy beliefs. Responsiveness was assessed by testing 16 a priori formulated hypotheses regarding effect sizes, areas under the curve, and correlations with changes in other instruments measuring other constructs. The MIC was calculated using an external anchor specific for pain self-efficacy and the receiver operator characteristic (ROC) method. The PSEQ and the PSEQ-4 met all hypotheses, whereas the PSEQ-2 met all but 1. The MICs were 5.5 for the PSEQ (9% of the scale range) and 1.5 for PSEQ-2 (13% scale range) and PSEQ-4 (6% scale range). MIC values were different for patients with low or high baseline values for all 3 instruments. The PSEQ and its short versions are adequately responsive instruments in patients with CLBP.

PERSPECTIVE

This study suggests that the PSEQ and its short versions are responsive measures of pain self-efficacy in patients with CLBP, adding to previous literature on their validity and reliability. Considering their similar responsiveness, the 4-item PSEQ could replace the original 10-item version in busy clinical or research settings.

Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis

Nonspecific chronic spinal pain (NSCSP) is highly disabling. Current conservative rehabilitation commonly includes physical and behavioral interventions, or a combination of these approaches. Physical interventions aim to enhance physical capacity by using methods such as exercise, manual therapy, and ergonomics. Behavioral/psychologically informed interventions aim to enhance behaviors, cognitions, or mood by using methods such as relaxation and cognitive behavioral therapy. Combined interventions aim to target physical and also behavioral/psychological factors contributing to patients' pain by using methods such as multidisciplinary pain management programs. Because it remains unclear whether any of these approaches are superior, this review aimed to assess the comparative effectiveness of physical, behavioral/psychologically informed, and combined interventions on pain and disability in patients with NSCSP. Ten electronic databases were searched for randomized controlled trials (RCTs) including participants reporting NSCSP. Studies were required to have an "active" conservative treatment control group for comparison. Studies were not eligible if the interventions were from the same domain (eg, if the study compared 2 physical interventions). Study quality was assessed used the Cochrane Back Review Group risk of bias criteria. The treatment effects of physical, behavioral/psychologically informed, and combined interventions were assessed using meta-analyses. Twenty-four studies were included. No clinically significant differences were found for pain and disability between physical, behavioral/psychologically informed, and combined interventions. The simple categorization of interventions into physical, behavioral/psychologically informed, and combined could be considered a limitation of this review, because these interventions may not be easily differentiated to allow accurate comparisons to be made. Further work should consider investigating whether tailoring rehabilitation to individual patients and their perceived risk of chronicity, as seen in recent RCTs for low back pain, can enhance outcomes in NSCSP.

PERSPECTIVE

In this systematic review of RCTs in NSCSP, only small differences in pain or disability were observed between physical, behavioral/psychologically informed, and combined interventions.

Pain Self-Efficacy and Fear of Movement are Similarly Associated with Pain Intensity and Disability in Italian Patients with Chronic Low Back Pain

The purpose of this study was to investigate cross-sectional associations of pain self-efficacy and fear of movement with pain intensity and disability in Italian patients with chronic low back pain (CLBP). One hundred and three adult outpatients with nonspecific CLBP were included in the study. Socio-demographic and clinical characteristics were assessed, together with Italian versions of self-reported questionnaires to measure the four constructs of interest. Multiple linear regression models were built with psychosocial constructs as main determinants, and pain intensity and disability as outcomes. Potential confounding of socio-demographic and clinical characteristics was assessed. Pain self-efficacy and fear of movement displayed moderate correlations with pain intensity (r = -0.41 and 0.42, respectively) and disability (-0.55 and 0.54). Association models adjusted for pain intensity showed that both pain self-efficacy (β = -0.35, 95% CI = -0.5; -0.2, R²  = 41%) and fear of movement (β = 0.65, 95% CI = 0.36; 0.93, R²  = 40%) are significantly and strongly associated with disability. Pain self-efficacy was no longer significantly associated with pain intensity when disability was added as a confounder to the model, whereas fear of movement retained its significant association (β = 0.06, 95% CI = 0.00;0.11, R²  = 30%). No other variables acted as confounders in these associations. Pain self-efficacy and fear of movement are very similarly associated with main outcomes in this sample of Italian patients with CLBP. The results of this study suggest that both psychosocial constructs should be considered in clinical management. Future studies should investigate whether these findings can be replicated in other samples, in longitudinal designs and if other variables not measured in this study confound the associations.

[The effect of pain on quality of life before and after the surgical treatment of lumbar vertebral canal stenosis]

OBJECTIVE

To evaluate the efficacy of surgical treatment of lumbar vertebral canal stenosis based on the study of patient's pain and emotional status, quality of life and level of disability before and after surgical treatment.

MATERIAL AND METHODS

A complex examination of 163 patients with lumbar vertebral canal stenosis was carried out. The visual analogous scale, Paindetect (PD) and Douleur neuropathique 4 (DN4), the Chronic Pain Coping Inventory, the Oswestry low back pain disability questionnaire were used. Affective disorders were measured using Beck depression scale. Blood serum and thrombocytic serotonin were determined with ELISA. Patients were examined at admission before the surgery, at discharge from the hospital after surgical treatment and one year after the surgery.

RESULTS AND CONCLUSION

Before surgery, the patients had chronic pain syndrome of mixed etiology (nociceptive and neurotic type) and neurological disorders that significantly affected quality of life and work capacity. Neuropathic pain and depression, reduced quality of life and daily activities were more pronounced in patients with central canal stenosis compared to patients with lateral stenosis. The timely surgical treatment of lumbar vertebral canal stenosis promoted the decompression of nervous structures. A significant reduction of pain syndrome and the level of depression as well as the improvement of quality of life were observed.

A pilot study - the potential value of an activity-based feedback system for treatment of individuals with chronic lower back pain

PURPOSE

The aim of this pilot study was to evaluate the potential value of a new personalized activity-based feedback treatment.

METHOD

A prognostic cohort study was carried out in the daily environment of the patients. Seventeen individuals with chronic lower back pain (CLBP) symptoms for >3 months were included. Patients were from the Netherlands, aged 18-65 years. Patients wore an accelerometer and a Personal Digital Assistant (PDA) for 15 d. Patients received continuous and time-related personalized feedback and were instructed to follow the activity pattern as displayed on the PDA. Technical performance and compliance with the system were rated. Objective and subjective activity scores were compared for exploring awareness. The absolute difference between the activity pattern of the patient and the norm value used was calculated and expressed as mean difference. Pain intensity was measured using the VAS.

RESULTS

The technical performance and compliance with the system were rated moderate. More than half of the patients were aware of their activity level during the feedback days (67%). A positive effect of the feedback was seen in a trend which showed a decrease in the absolute difference between the activity pattern of the patient and the norm value (p = 0.149) and a significant decrease in pain intensity levels (p = 0.005).

CONCLUSIONS

This pilot study suggested that an individual-tailored feedback system that focuses on the activity behavior of the patient has potential as the treatment of individuals with CLBP. Implications for Rehabilitation Activity-based feedback for individuals with chronic low back pain: Many patients are not aware of their activity patterns. The activity patterns of patients differ from those of healthy controls. It is important to make patients aware of their activity patterns in order to change activity behavior. An individual-tailored feedback system seems promising in decreasing pain intensity levels for a subgroup of patients.

Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain: a randomized controlled trial

Objective:

The aim of this study was to compare the effectiveness of a combination of aquatic exercise and pain neurophysiology education with aquatic exercise alone in chronic low back pain patients.

Design:

Single-blind randomized controlled trial.

Setting:

Outpatient clinic.

Subjects:

Sixty-two chronic low back pain patients were randomly allocated to receive aquatic exercise and pain neurophysiology education ( n = 30) or aquatic exercise alone ( n = 32).

Interventions:

Twelve sessions of a 6-week aquatic exercise programme preceded by 2 sessions of pain neurophysiology education. Controls received only 12 sessions of the 6-week aquatic exercise programme.

Main measures:

The primary outcomes were pain intensity (Visual Analogue Scale) and functional disability (Quebec Back Pain Disability Scale) at the baseline, 6 weeks after the beginning of the aquatic exercise programme and at the 3 months follow-up. Secondary outcome was kinesiophobia (Tampa Scale of Kinesiophobia).

Results:

Fifty-five participants completed the study. Analysis using mixed-model ANOVA revealed a significant treatment condition interaction on pain intensity at the 3 months follow-up, favoring the education group (mean SD change: −25.4± 26.7 vs −6.6 ± 30.7, P < 0.005). Although participants in the education group were more likely to report perceived functional benefits from treatment at 3 months follow-up (RR=1.63, 95%CI: 1.01–2.63), no significant differences were found in functional disability and kinesiophobia between groups at any time.

Conclusions:

This study’s findings support the provision of pain neurophysiology education as a clinically effective addition to aquatic exercise.