Psychosocial issues in the prevention of chronic low back pain--a literature review

Biofeedback EMG alternative therapy for chronic low back pain: Study protocol of a pilot randomized controlled trial

BACKGROUND

Chronic pain affects about 100 million U.S. adults, with chronic low back pain (CLBP) cited as the most prevalent type. Although there is evidence that non-pharmacological therapies seem to be effective for treating low back pain, there is limited evidence of the effectiveness of EMG biofeedback with non-specific chronic low back pain (NCLBP). The purpose of this study is, therefore, to determine the efficacy of a portable EMG biofeedback device on pain in individuals with CLBP.

METHODS/DESIGN

This study is a prospective, single-center, assessor-blind, two-arm, parallel randomized controlled trial to be conducted at Brigham and Women's Hospital, Boston, MA. Eighty patients with CLBP will be randomized in a 2:1 ratio to receive sEMG-BF (surface EMG biofeedback) or continued care (no intervention). All participants will receive treatment virtually weekly for 8 weeks. The primary outcome will be pain intensity (Brief Pain Inventory). The secondary outcomes will include pain interference (Brief Pain Inventory), disability (The Oswestry Disability Index (ODI)), anxiety and depression (Hospital Anxiety and Depression Scale). All outcomes will be assessed at baseline, immediately post-intervention, and 3 months follow-up.

CONCLUSION

To our knowledge, this study will be the first powered randomized controlled trial to compare the effectiveness of a virtual sEMG-BF protocol specifically designed for CLBP. The outcome of the study may provide evidence for the effectiveness of biofeedback using digital therapeutics to relieve pain in individuals with CLBP.

TRIAL REGISTRATION

Clinical Trials Registry (http://ClinicalTrials.gov Identifier: NCT04607460). Registered on October 29, 2020.

Prevalent musculoskeletal pain as a correlate of previous exposure to torture

Aim: To research possible associations between previous exposure to specific torture techniques and prevalent pain in the head and face, back, and feet. Methods: 221 refugees, 193 males and 28 females, previously exposed to torture in their home country, were subject to a clinical interview at a rehabilitation clinic for torture victims. The interview focused on exposure to torture and somatic symptoms prevalent at examination. Results: The mean number of times imprisoned was 2.3; the mean number of months imprisoned was 19.7; the mean duration from initial imprisonment to final release was 3.7 years; and the mean duration from final release to preliminary interview was 8.4 years. The most frequent physical torture method reported was beating (92.3%) and the main mental torture method was deprivation (84.6%). Pain in the head and face was found to be strongly associated with torture against head and face (OR 3.89, 95% CI 1.49—10.20) and with the cumulative number of physical torture methods exposed to. Pain in the back was associated with sexual torture (OR 2.75, 95% CI 1.07—7.12). Besides beating of the lower extremities (OR 5.98, 95% CI 2.47—14.48), the strongest predictor for pain in the feet was general abuse of the whole body (OR 5.64, 95% CI 1.93—16.45). Conclusion: In spite of many factors being potentially co-responsible for prevalent pain, years after the torture took place it presents itself as strongly associated with specific loci of pain, with generalized effects, and with somatizing.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN/SETTING

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

PATIENT SAMPLE

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

OUTCOME MEASURES

Pain, disability, and catastrophizing measured through validated instruments.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fear-avoidance beliefs and pain coping strategies in relation to lower back problems in a South African steel industry

The objective was to determine the association between the prevalence of lower back problems (LBP), fear-avoidance beliefs and pain coping strategies using an analytical cross-sectional epidemiological study among a group of 366 workers in a South African stainless steel industry. Outcome (LBP) was defined using a questionnaire and a functional rating index. Exposure to psychosocial risk was determined using the Fear-Avoidance Beliefs (FABQ) and Coping Strategies (CSQ) questionnaires. Multivariate logistic regression analyses for LBP indicated the following significant risk factors: work-related fear-avoidance beliefs (OR 3.40; 95% CI 2.20-5.25), catastrophizing (1.31; 1.01-1.7) and pain coping self statements (1.47; 1.16-1.87). Significant protective associations were found for increased activity levels (OR 0.57; 95% CI 0.42-0.78). These findings have utility in preventative screening procedures to identify workers with such beliefs and coping strategies who are at risk for prolonged work restrictions.

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

This study aimed to conduct a comprehensive evaluation of background, individual and workplace psychological risk factors to investigated their relationship with spinal pain. Because there is some doubt as to whether the results of cross-sectional findings hold in longitudinal studies, a prospective study was superimposed upon a cross-sectional design of the effects of psychological variables on back pain and function to determine, whether similar results are obtained. Participants were workers randomly selected from the general population, where 372 had not experienced pain during the past year, and 209 had experienced considerable pain problems. A cross-sectional comparison of these groups using multivariate statistics indicated that the most potent risk factors were psychological distress (odds ratio=13.2) and poor function (odds ratio=6.4). Much smaller levels of risk were found for perceived workload, gender and foreign birth. Those participants with no pain were followed for one year to determine development of a spinal pain problem. Although few participants developed a significant pain problem, the prospective analyses showed that psychological distress (odds ratio=2.2), catastrophizing (odds ratio=3.0), and workload (odds ratio=2.3) produced the highest odds ratios. Taken together these results underscore the need for a multidimensional view of the development of pain disability. Moreover, individual psychological factors such as distress and catastrophizing as well as work place factors like work load were found to be highly related to the development of back pain in a sample of workers from the general population. The cross-sectional and prospective results were similar in character and demonstrate that cross-sectional studies may provide valuable information. Because psychological variables were relevant very early on, these factors may be important targets for pain prevention programs.

Multidisciplinary rehabilitation for chronic back pain in an outpatient setting: A controlled randomized trial

Based on existing models for pain chronicity and effective treatment strategies for patients with chronic low back pain, a multidisciplinary rehabilitation programme for an outpatient group setting was developed. The main treatment components address the patient's physical functional capacity (functional restoring), cognitive and affective processes (pain management strategies), and behavioural and ergonomical aspects (back school elements). Short-term (immediately after intervention) and long-term effects (at 6-months follow-up) of the intervention were assessed in a randomized controlled study. Dependent variables were pain measures, functional capacity, disability, muscular strength and endurance, pain and posture-related self-efficacy, attitudes, depression, well-being, behavioural habits and posture assessed by a standardized behavioural observation method. Immediately after the intervention, patients in the treatment group (n=36) showed significant improvement over patients in the control group (n=29) in all variables except depression and muscular strength and endurance. At 6-months follow-up, compared to pretreatment scores, patients continued to show beneficial effects in pain intensity and frequency, posture, posture-related self-efficacy and well-being. In contrast to post-treatment results, there were also significant improvements in strength and endurance. Overall results testify to the effectiveness of the intervention programme. Future studies (with larger sample sizes) should aim at a further improvement of functional capacity and disability perception, an analysis of differential treatment effects, and strategies for an improved long-term maintenance of the changes induced by the programme.

The diagnostic accuracy of brief screening questions for psychosocial risk factors of poor outcome from an episode of pain: A systematic review

OBJECTIVE

To determine the diagnostic accuracy of brief screening questions for psychosocial risk factors predictive of poor outcome from an episode of pain.

METHODS

Six electronic databases were searched, content experts contacted, and reference and citation tracking performed. Studies were included that examined the diagnostic accuracy of 1-item screening or 2-item screening questions for depression, anxiety, fear-avoidance beliefs, social isolation, catastrophization, or somatization and were published in English. Studies were assessed for quality, and data extracted describing study characteristics and the diagnostic accuracy of brief screening questions.

RESULTS

Four cross-sectional studies met the inclusion criteria and all met 4 or more of our 6 method quality criteria. These studies examined the diagnostic accuracy of brief screening tools for depression (sensitivity = 50.5% to 82.1%, specificity = 71.0% to 90.6%, and overall accuracy = 74.6% to 80.6%) and anxiety (sensitivity 63.0% to 94.0%, specificity = 53.0% to 71.2%, and overall accuracy = 60.0% to 68.1%). No studies were identified that examined the diagnostic accuracy of brief screening questions for fear-avoidance beliefs, social isolation, catastrophization, and somatization.

DISCUSSION

Data were only available on the accuracy of brief screening instruments for depression and anxiety, and there was variability in the results. Head-to-head studies are required to determine if this variability reflects differential question accuracy or population characteristics, and studies that determine the diagnostic accuracy of brief screening questions for other common psychosocial risk factors would be useful.

The value of physical performance tests for predicting therapy outcome in patients with subacute low back pain: a prospective cohort study

Considering the enormous costs of intensive multidisciplinary treatment, predictive tests for therapy outcome are needed to evaluate patients' performance potential and increase cost effectiveness. Somatic parameters are commonly used to evaluate health status and serve as an additional means of forecasting the prognosis, yet little is known of their validity. In this study, we investigated the prognostic value of somatic parameters regarding the outcome of multidisciplinary treatment in patients with subacute low back pain. The study was designed as a prospective cohort study of 162 patients. Somatic parameters were assessed with three physical performance tests (Villiger test, Oesch test, Biering-Sørensen test) before treatment (T0), after 3 weeks' inpatient therapy (T1) and at 6-month follow-up (T2). Psychometric characteristics of subjective pain perception (VAS), a pain disability index (PDI) and a physical capability index (FFbH-R) were recorded. Correlation coefficients between the physical performance test scores and psychometric characteristics were calculated. To predict therapy outcome, discriminant analyses were performed. A control group (n = 30) was evaluated at similar time points without receiving any therapy. Our results demonstrate good discrimination between patients and controls by means of the investigated performance tests and exhibit a significant negative correlation with the psychometric data. Lower outcome values at study entry correlated with higher pain intensity and disability after multidisciplinary treatment. However, the statistical magnitude of correlation was relatively low and further discriminant analysis did not reveal any predictive value. Consequently the physical performance tests do not have a prognostic value regarding therapy outcome.

Effect of an education and activation programme on functional limitations and patient-perceived recovery in acute and sub-acute shoulder complaints - a randomised clinical trial

BACKGROUND

The education and activation programme (EAP) aims at coping with psychosocial determinants to prevent the development of chronic shoulder complaints (SCs). The effect of the EAP on functional limitations and patient-perceived recovery after 6 and 26 weeks is evaluated in a randomised clinical trial.

METHODS

Patients with SCs present at rest or elicited by movement and lasting no longer than 3 months were allocated at random to either EAP as an addition to usual care (UC), or to UC only. Measurements were taken at baseline and after 6 and 26 weeks and were analysed by means of multilevel analysis for the group effect. EAP was administered by GPs or by an ambulant therapist (CDB). Patients in the UC group were given UC by their own GP.

RESULTS

Multilevel analysis failed to show a significant effect of the EAP on either functional limitations or patient-perceived recovery. Analysis showed coincidentally a relation between catastrophising at baseline and functional limitations.

CONCLUSION

The EAP has no significant effect on the outcome of SCs after 6 and 26 weeks. The relation between catastrophising at baseline and functional limitations suggests that an intervention focusing specifically on catastrophising may be more successful in reducing functional limitations in the long term. Further research is however needed to evaluate the effect of catastrophising at baseline on the course of SCs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71777817.

Cost-effectiveness of an education and activation program for patients with acute and subacute shoulder complaints compared to usual care

OBJECTIVES

Shoulder complaints (SCs) constitute the second largest group of musculoskeletal disorders after low back pain. The economic burden in terms of costs of healthcare use and costs due to work absenteeism underlines the need for a cost-effectiveness analysis of the interventions involved. The education and activation program (EAP) is a newly developed early intervention to prevent the development of chronic SCs. A cost-effectiveness analysis should provide more information on the effect of an EAP on total costs related to SCs.

METHODS

We conducted a cost-effectiveness analysis alongside a randomized clinical trial comparing the effectiveness of the EAP in addition to usual care (EAP group) with that of usual care alone (UC group) in terms of preventing chronicity in patients with acute SCs. The aim of the cost-effectiveness analysis was to compare the observed difference in costs with the clinical effectiveness (i.e., patient-perceived recovery after 26 weeks), using bootstraps.

RESULTS

The comparison of total costs between treatment groups showed no significant (p = .077) difference after 26 weeks. The majority (82 percent) of the cost-effect pairs after bootstrap analysis were located in the northeast quadrant, suggesting more effect but at higher costs.

CONCLUSIONS

In view of the clinical relevance of the clinical outcomes and the considerable costs needed to achieve this, it can be concluded that the EAP is currently not cost-effective.

General practitioners apply the usual care for shoulder complaints better than expected--analysis of videotaped consultations

Background

The education and activation program (EAP) is a newly developed intervention to prevent the development of chronic shoulder complaints (SCs). Trained general practitioners (GPs) administer the EAP. The EAP addresses inadequate cognitions and maladaptive behavior related to the SCs. The effect of the EAP is evaluated in a randomized clinical trial.

The aim of the present study is to use videotaped consultations to study (1) the performance of trained GPs administering the EAP and (2) the presence of key features of the EAP already embedded in usual care (UC).

Methods

Five trained GPs were videotaped while treating a standardized patient with EAP. Additionally, five GPs administering UC were videotaped. Two blinded observers evaluated the videotapes in relation to key features of the EAP which were scored on the EAP checklist.

Results

The mean total score on the EAP checklist was 4.7 (SD = 2.9) for the UC group and 7.1 (SD = 2.1) for the EAP group. Neither group reached a score higher than 8, which was considered to reflect an acceptable number of key EAP features.

Conclusion

Our comparison of the presence of key features of EAP shows that the UC and EAP groups differed less than was expected. GPs in the UC group performed above expectation, with a mean total score of 4.7. Moreover, the low number of key features present in the EAP group may very well have led to a reduced effectiveness of the EAP. The results of this study can be used to optimize the training of GPs using the EAP.

How to identify patients with a poor prognosis in daily clinical practice

Predicting poor outcomes in daily practice is challenging. As well as prior episodes of low back pain and pain intensity, various psychosocial risk factors have been identified, although the independent prognostic value of these is rather low. This supports the necessity for a multidimensional view of the transition from acute to chronic pain and/or the development of disability. Psychological distress has been found to increase the risk of such a transition. Patients' beliefs and expectations about their pain seem to influence the recovery process; pain-related fear and fear avoidance can be influential psychological variables, from pain inception to its chronic stage. The influence of occupational factors such as job satisfaction, low workplace support or physical workload has also been emphasized. Treatment provider factors and the relationship between patients and care providers also contribute to the realistic or unrealistic expectations and meaningful or acceptable outcomes.

Psychosocial factors related to lower back problems in a South African manganese industry

The purpose of this study was to determine the association between the prevalence of lower back problems, fear-avoidance beliefs, and pain-coping strategies in using an analytical cross-sectional epidemiological study among a group of 109 workers in a South African manganese industry. Outcome (LBP) was defined using a guided questionnaire and functional rating indexes. Exposure to psychosocial risk was determined using the Fear-Avoidance Beliefs (FABQ) and Coping Strategies (CSQ) questionnaires. Using inclusive and stringent definitions for perceived LBP, point prevalence was 37.6 and 29.4%, respectively. Only 8 cases of LBP were, however; recorded officially over a 7-year period reflecting a tendency of underreporting. Multivariate logistic regression analyses indicated significant adjusted relative risk ratios (RR) for work-related fear-avoidance beliefs (RR 2.35; 95% CI 1.39-3.95) as a singular psychosocial risk while no specific coping strategy could be isolated. In conclusion, work hardening and a contented ethos of the manual laborers under study moderates the association between the prevalence and etiology of LBP.

A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation-or, back school treatment outcome in patients with chronic low back pain

STUDY DESIGN

A systematic review.

OBJECTIVE

To determine predictors of outcome of multidisciplinary rehabilitation-or back school treatment for patients with chronic low back pain.

SUMMARY OF BACKGROUND DATA

Numerous reviews have been performed to gain insight into which patients benefit from which treatment. However, no review has systematically focused on predictors from multiple domains (i.e., sociodemographic, physical, and psychological), or on treatment outcome measured as activity limitation or participation restriction.

METHODS

Studies were found by searching medical and psychological databases, and screening references. Two reviewers independently assessed the methodological quality using standard criteria. Studies were only included if they met a predefined level of internal validity. A qualitative analysis was performed.

RESULTS

Heterogeneity among studies in patient characteristics, predictors, treatment, and outcomes limited evidence. All reviewed studies were descriptive or exploratory in nature. Consistent evidence was found for the predictive value of pain intensity (more pain--> worse outcome), several work-related parameters (e.g., high satisfaction--> better outcome), and coping style (less active coping--> better outcome). Other sociodemographic and physical variables consistently lacked predictive value. No consistent evidence was found for other psychological variables.

CONCLUSIONS

It is impossible to define a generic set of predictors of outcome of multidisciplinary rehabilitation and back schools for patients with chronic low back pain because the reviewed studies were descriptive or exploratory in nature, and most predictors were only studied once. Nevertheless, for several predictors, consistent evidence was found. Large confirmatory studies are needed to test the value of these predictors.

Evaluation of an education and activation programme to prevent chronic shoulder complaints: design of an RCT [ISRCTN71777817]

BACKGROUND

About half of all newly presented episodes of shoulder complaints (SC) in general practice are reported to last for at least six months. Early interventions aimed at the psychological and social determinants of SC are not common in general practice, although such interventions might prevent the development of chronic SC. The Education and Activation Programme (EAP) consists of an educational part and a time-contingent activation part. The aim of the EAP is to provide patients with the proper cognitions by means of education, and to stimulate adequate behaviour through advice on activities of daily living.

DESIGN

The article describes the design of a randomised clinical trial (RCT) to evaluate the effectiveness and cost-effectiveness of an EAP in addition to usual care, compared to usual care only, in the prevention of chronic SC after six months. It also describes the analysis of the cost and effect balance. Patients suffering from SC for less than three months are recruited in general practice and through open recruitment. A trained general practitioner or a trained therapist administers the EAP.Primary outcome measures are patient-perceived recovery, measured by self-assessment on a seven-point scale, and functional limitations in activities of daily living. Questionnaires are used to study baseline measures, prognostic measures, process measures and outcome measures.

DISCUSSION

The inclusion of patients in the study lasted until December 31st 2003. Data collection is to end in June 2004.

A randomized controlled trial of intensive neurophysiology education in chronic low back pain

OBJECTIVES

Cognitive-behavioral pain management programs typically achieve improvements in pain cognitions, disability, and physical performance. However, it is not known whether the neurophysiology education component of such programs contributes to these outcomes. In chronic low back pain patients, we investigated the effect of neurophysiology education on cognitions, disability, and physical performance.

METHODS

This study was a blinded randomized controlled trial. Individual education sessions on neurophysiology of pain (experimental group) and back anatomy and physiology (control group) were conducted by trained physical therapist educators. Cognitions were evaluated using the Survey of Pain Attitudes (revised) (SOPA(R)), and the Pain Catastrophizing Scale (PCS). Behavioral measures included the Roland Morris Disability Questionnaire (RMDQ), and 3 physical performance tasks; (1) straight leg raise (SLR), (2) forward bending range, and (3) an abdominal "drawing-in" task, which provides a measure of voluntary activation of the deep abdominal muscles. Methodological checks evaluated non-specific effects of intervention.

RESULTS

There was a significant treatment effect on the SOPA(R), PCS, SLR, and forward bending. There was a statistically significant effect on RMDQ; however, the size of this effect was small and probably not clinically meaningful.

DISCUSSION

Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability. The results suggest that pain neurophysiology education, but not back school type education, should be included in a wider pain management approach.

Patients' perspectives on self-management following a back rehabilitation programme

OBJECTIVE

The management of chronic low back pain (CLBP) is becoming increasingly demanding upon health care services and society. Programmes combining exercise, education and a biopsychosocial approach have become a popular way of managing CLBP. Programmes are designed to change behaviour, increase activity levels and encourage self-management. Patients' experiences of attending a back rehabilitation programme were examined.

METHODS

This study used a qualitative approach combining interviews, non-participant observation and evaluation of documentation to establish the patients' perspective of self-management following a back programme.

RESULTS

All the patients (n = 6 ) indicated they were self-managing by continuing to exercise and utilizing the advice given after attendance. Two patients felt they should continue attending the therapy department to exercise in order to gain benefit, demonstrating reliance on continued health care support. Obstacles to continuing with exercise were cited as pain, time, and family constraints. Patients also expressed limitations following attendance regarding the type and level of activity their CLBP would allow them to manage. The data suggested activity limitation was inadvertently reinforced by the therapists during the sessions, in the programme letter and by the patients' existing beliefs regarding the cause of their CLBP.

CONCLUSION

The study demonstrated the importance of understanding patients' beliefs and expectations prior to a back programme and accounting for these during attendance. This study also highlighted that all heath care professionals should be aware of the impact of the language and terminology used when working with CLBP patients.

Low back pain in Flemish adolescents and the role of perceived social support and effect on the perception of back pain

AIM

To document the prevalence of low back pain (LBP) in Flemish adolescents and to recognize the association between perceived social support and affect and medical consultation and reduction of activities.

METHODS

The study comprised 620 adolescents. A questionnaire was used to elicit the characteristics of LBP. Perceived social support and affect were investigated using the Personal Resource Questionnaire (PRQ) and the Positive Affect Negative Affect Scale (PANAS), respectively. Comparisons were made between adolescents with LBP and adolescents without LBP. Within the LBP group, answers from adolescents appealing for medical advice were compared with those who did not seek advice. Another comparison was done between adolescents who reduced their activities and those who did not. Descriptive statistics, the median test for two samples, a chi2 test or Fisher's exact probability test and logistic regression analysis were used for data analysis.

RESULTS

Month prevalence of LBP was 24.7%. Thirteen adolescents visited a physician or received treatment, pain severity being the sole factor associated with the decision. Fifteen adolescents reduced their sports activities and 11 reduced or stopped other leisure activities. Pain severity and negative affect were the main associated factors.

CONCLUSION

The results of the present study encourage further research on the role of pain perception and the influence of psychosocial factors on back pain in adolescents.

Early identification and intervention in the prevention of musculoskeletal pain

BACKGROUND

A large number of people suffer from upper extremity disorders, but a few apparently consume the majority of the resources. Early interventions are badly needed to prevent the development of persistent disability. Since psychological factors are central in the development of a chronic problem these might be utilized in this endeavor.

METHODS

A series of studies are described where a screening procedure based on psychological risk factors was employed to help identify people at risk for developing long-term work disability. The utility of a cognitive-behavioral group intervention that focuses on coping strategies as prevention was assessed in three randomized-controlled studies where participants had low, medium, and high risk, respectively.

RESULTS

The study with low risk showed no significant difference between the groups, while the studies with medium- and high-risk populations demonstrated significantly lower work disability than control groups receiving treatment as usual.

CONCLUSIONS

It appears to be feasible to identify patients with high levels of risk and to subsequently lower the risk for work disability by administering a cognitive-behavioral intervention focusing on psychological aspects of the pain problem.

Evaluation of a randomized preventive behavioural medicine work site intervention for public health workers at risk for developing chronic pain

Because of the substantial increase of sick listing, reports of work disabilities and early retirement due to the musculoskeletal chronic pain, prevention studies at the work site are greatly needed. The purpose of the present study was to investigate the effects of a cognitive behavioural work site intervention on a group of public health workers judged to be at risk for developing chronic pain. Following baseline measurements, a group of 29 practical nurses with daily pain symptoms working at services for the elderly were randomized into two conditions: an active treatment based on cognitive behaviour therapy and a passive treatment based on traditional symptom alleviation. The two treatment conditions, provided by a registered nurse and a physical therapist, took place 30 min a week each once a week, on an individual basis for 4 weeks at the work site during work time. Results at 4 and 8 weeks and at 6, 12 and 24 month follow-ups showed improvements for those individuals receiving the active treatment with regard to the reduction of use of pain-killers, perception of one's self as being sick and the fear-avoidance response to work-related activities. A preliminary conclusion was that this short-term work site programme for the prevention of chronic pain for individuals at risk may be a promising development in the treatment of pain.

Industrial medicine and acute musculoskeletal rehabilitation. 5. Effective medical management of industrial injuries: from causality to case closure

This self-directed learning module highlights the physician's role in treating industrial injuries, from the initial causality determination to the eventual case closure. It is part of the chapter on industrial medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The article reviews important factors in determining whether an injury is work-related, particularly in the presence of preexisting, underlying conditions. The article addresses the roles of functional capacity examinations and work-hardening programs in facilitating successful return to work. Interactions are outlined between work return and nonwork activities of daily living, as well as financial and psychologic barriers that may impede work return. Legal issues regarding independent medical examinations and depositions are reviewed. Guidance is offered for identifying those relatively few injured workers who may require referral for surgical or other consultations.

OVERALL ARTICLE OBJECTIVES

(a) To review the important medical, administrative, and legal challenges involved in treating injured workers and to describe strategies that physiatrists use to overcome effectively these challenges.

Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain

In general, randomized controlled studies concerning return to work have failed to demonstrate significant treatment effects for long-lasting musculoskeletal pain, and most treatments examined have not been economically beneficial. Individuals (n=654) sick-listed for at least 8 weeks with musculoskeletal pain, selected from the Norwegian mandatory sickness insurance system and volunteering to participate, were categorized into three groups differing in a prognosis score (good, medium, poor) for return to work, based on a brief, standardized screening of psychological and physiotherapy findings. They were then randomly assigned to three outpatient treatments with three different levels of intensity (ordinary treatment, light multidisciplinary, and extensive multidisciplinary treatment). The evaluation was based on 14 months follow-up data on return to work collected from social security records. The patients with good prognosis for return to work do equally well with ordinary treatment as with the two more intensive treatments. The patients with medium prognosis benefit equally from the two multidisciplinary treatments. The patients with poor prognosis receiving extensive multidisciplinary treatment returned to work at a higher rate than patients with poor prognosis receiving ordinary treatment, 55 vs. 37% (P<0.05) at 14 months. Multidisciplinary treatment is effective concerning return to work, when given to patients who are most likely to benefit from that treatment. Measures of pain or quality of life are not included in this study. The cost-benefit analysis of the economic returns of the light multidisciplinary and the extensive multidisciplinary treatment programs yields a positive net present social value of the treatment. A simple, standardized, screening instrument including only psychological and physiotherapeutic observations may be a useful clinical tool for allocating patients with musculoskeletal pain to the right level of treatment.

Working with low back pain: problem-solving orientation and function

A number of ergonomic, workplace and individual psychosocial factors and health behaviors have been associated with the onset, exacerbation and/or maintenance of low back pain (LBP). The functional impact of these factors may be influenced by how a worker approaches problems in general. The present study was conducted to determine whether problem-solving orientation was associated with physical and mental health outcomes in fully employed workers (soldiers) reporting a history of LBP in the past year. The sample consisted of 475 soldiers (446 male, 29 female; mean age 24.5 years) who worked in jobs identified as high risk for LBP-related disability and reported LBP symptoms in the past 12 months. The Social Problem-Solving Inventory and the Standard Form-12 (SF-12) were completed by all subjects. Hierarchical multiple regression analyses were used to predict the SF-12 physical health summary scale from interactions of LBP symptoms with each of five problem-solving subscales. Low scores on positive problem-solving orientation (F(1,457)=4.49), and high scores on impulsivity/carelessness (F(1,457)=9.11) were associated with a steeper gradient in functional loss related to LBP. Among those with a longer history of low-grade LBP, an avoidant approach to problem-solving was also associated with a steeper gradient of functional loss (three-way interaction; F(1,458)=4.58). These results suggest that the prolonged impact of LBP on daily function may be reduced by assisting affected workers to conceptualize LBP as a problem that can be overcome and using strategies that promote taking an active role in reducing risks for LBP. Secondary prevention efforts may be improved by addressing these factors.

A cognitive-behavioral group intervention as prevention for persistent neck and back pain in a non-patient population: a randomized controlled trial

Given the demand for interventions that may prevent the development of persistent musculoskeletal pain problems, we investigated the effects of a cognitive-behavioral program in a group of non-patients with neck or back pain symptoms. Two hundred and fifty-three people selected from a population study were invited to participate. These people had experienced four or more episodes of relatively intense spinal pain during the past year but had not been out of work more than 30 days. Participants were randomly assigned to either a cognitive-behavioral group intervention or a treatment as usual comparison group. The experimental group received a standardized six-session program, provided by a trained therapist according to a manual. A significant overall analysis at the 1-year follow-up showed that the cognitive-behavioral group produced better results on 26 of the 33 outcome variables. Group comparisons indicated that the cognitive-behavioral group, relative to the comparison group, had significantly better results with regard to fear-avoidance beliefs, number of pain-free days, as well as the key variable of sick leave. Participation in the cognitive behavioral group reduced the risk for long-term sick leave during the follow-up by threefold. Thus, despite the strong natural recovery rate for back pain, the cognitive-behavioral intervention produced a significant preventive effect with regard to disability.

Relationships between physical findings (GPE-78) and psychological profiles (MMPI-2) in patients with long-lasting musculoskeletal pain

The purpose of the study was to evaluate possible relationships between physical findings, as measured with the Global Physiotherapeutic Examination (GPE-78), and psychological characteristics, as measured with the revised Minnesota Multiphasic Personality Inventory (MMPI-2), in three groups of patients with long-lasting musculoskeletal pain. A total of 177 patients (114 women, 63 men), sick-listed owing to long-lasting musculoskeletal pain, were studied. The sample was subcategorized on the basis of pain localization, as marked on a pain drawing: group 1 = pain above a horizontal line in the thoracic-lumbar region (n = 24); group 2 = pain below the line (n = 48); group 3 = pain both above and below the line (n = 105). The GPE-78 consists of 78 standardized tests yielding quantitative information within five bodily domains: Posture, Movement, Muscle, Skin, and Respiration. Significant correlations were obtained between the GPE-78 and the MMPI-2 with regard to somatization, somatic concern, and depression. Patients with localized pain (groups 1 and 2) had few correlations between bodily findings and psychological problems compared with many inpatients with generalized pain (group 3). Women showed correlations between the domains Posture, Movement, and Muscle and psychological problems, whereas men showed correlations with Movement, Skin and Respiration. A psychosomatic MMPI-2 "V-profile" was present in groups 1 and 3. Women showed significantly higher scores than men. The relationships found between GPE-78 and MMPI-2 measures were significant, but findings differed depending on pain localization and sex. Patients with generalized pain had significantly more physical and psychological aberrations than patients with more localized pain.

Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology

OBJECTIVE

To compare two different home exercise programmes for patients with acute whiplash-associated disorders (WAD). A further aim was to describe the initial prognostic variables related to self-reported pain at six months follow-up.

DESIGN

A randomized treatment study with a follow-up period of six months.

SETTINGS

The study was undertaken in an orthopaedic clinic at a university hospital.

SUBJECTS

A total of 59 symptomatic (neck pain, stiffness, etc.) patients with acute whiplash injury.

INTERVENTIONS

Patients were randomized to a regular treatment group (RT group) and an additional-exercise treatment group (AT group).

MAIN OUTCOME MEASURES

Pain Disability Index (PDI), Self-Efficacy Scale (SES), Coping Strategies Questionnaire (CSQ), neck range of motion (ROM), head posture, kinaesthetic sensibility, visual analogue scale (VAS).

RESULTS

Patients given an additional exercise did not improve more than patients with regular treatment. Only one CSQ item, 'Ability to decrease pain', showed a significant difference between the groups in its pattern of change over time: the AT group had a significant increase between three and six months whilst values in the RT group decreased. Nonsymptomatic patients at six months follow-up were characterized by initially better self-efficacy, lower disability and significantly different patterns in the use of 'behavioural coping strategies' when compared with symptomatic patients. The nonsymptomatic patients also reported more frequent training than symptomatic patients, i.e. they complied better with the treatment regime.

CONCLUSION

This home exercise programme, including training of neck and shoulder ROM, relaxation and general advice seems to be sufficient treatment for acute WAD patients when used on a daily basis. Additionally, patients reporting low self-efficacy and high disability levels may profit from more attention initially, as these psychological factors are significant predictors of pain at long-term follow-up.

A prospective follow-up study of low back pain in the community

STUDY DESIGN

Opportunistic prospective follow-up study.

OBJECTIVE

To describe the natural history of low back pain in the community and to model the factors predictive of recovered versus persistent low back pain.

SUMMARY OF BACKGROUND DATA

A two-phase questionnaire was mailed to adults in the Bradford Metropolitan Health District in 1994. Valid respondents were surveyed again in 1997. Analysis is based on the combined results of these two surveys.

METHODS

Unifactorial and multifactorial statistics were analyzed based on 1455 adults, with and without low back pain.

RESULTS

One third of respondents reported no lifetime low back pain. Average lifetime prevalence was 59% and average annual prevalence 41%. Of those who reported lifetime low back pain, 42% reported persistent annual low back pain, 18% reported a first episode in 1997, resulting in a 4% population incidence rate, and 40% reported intermittent low back pain. The likelihood of having had low back pain increased significantly with age. Those who reported a new case of low back pain in 1997 were significantly more likely to be 25-34 years of age, and these persons were most likely to report acute low back pain with very little disability. Those with persistent low back pain were significantly more likely to report chronic low back pain with some disability. Logistic regression modeling was unable to predict recovered versus persistent low back pain, given the person, pain, and treatment factors available.

CONCLUSIONS

Results showed that low back pain is a mutable problem with acute episodes blending into longer periods resulting in more disability as time progresses. A wide range of demographic, pain, consultation, and treatment factors were not predictive of low back pain recovery.

A review of psychological risk factors in back and neck pain

STUDY DESIGN

The literature on psychological factors in neck and back pain was systematically searched and reviewed.

OBJECTIVES

To summarize current knowledge concerning the role of psychological variables in the etiology and development of neck and back pain.

SUMMARY OF BACKGROUND DATA

Recent conceptions of spinal pain, especially chronic back pain, have highlighted the role of psychological factors. Numerous studies subsequently have examined the effects of various psychological factors in neck and back pain. There is a need to review this material to ascertain what conclusions may be drawn.

METHODS

Medical and psychological databases and cross-referencing were used to locate 913 potentially relevant articles. A table of 37 studies was constructed, consisting only of studies with prospective designs to ensure quality. Each study was reviewed for the population studied, the psychological predictor variables, and the outcome.

RESULTS

The available literature indicated a clear link between psychological variables and neck and back pain. The prospective studies indicated that psychological variables were related to the onset of pain, and to acute, subacute, and chronic pain. Stress, distress, or anxiety as well as mood and emotions, cognitive functioning, and pain behavior all were found to be significant factors. Personality factors produced mixed results. Although the level of evidence was low, abuse also was found to be a potentially significant factor.

CONCLUSIONS

Psychological factors play a significant role not only in chronic pain, but also in the etiology of acute pain, particularly in the transition to chronic problems. Specific types of psychological variables emerge and may be important in distinct developmental time frames, also implying that assessment and intervention need to reflect these variables. Still, psychological factors account for only a portion of the variance, thereby highlighting the multidimensional view. Because the methodologic quality of the studies varied considerably, future research should focus on improving quality and addressing new questions such as the mechanism, the developmental time factor, and the relevance that these risk factors have for intervention.

Stress management: an exploratory study of chiropractic patients

BACKGROUND

Stress is a recognized variable in the diagnosis, management, and prognosis of musculoskeletal conditions; chiropractic care is reputed to be successful in the management of stress-related visceral conditions. It may be useful for chiropractors to include stress management as a clinical care option.

OBJECTIVE

To explore screening tools to aid stress self-assessment, investigate patients' perceptions of stress management as a chiropractic care option, and examine which stress-management strategies chiropractic patients perceive as most useful.

DESIGN

A multiphase qualitative study with purposive sampling of chiropractic clinics to maximize the diversity of the patient population. Convenience sampling of patients was undertaken in a Western Australian case study, an inner city, and a national exploratory study. Data for the case study were collected by semistructured interview. Questionnaires and a self-assessed stress-management task were used to collect data from the inner city and national studies. Data was thematically analyzed, and results were triangulated.

RESULTS

The sample size of chiropractic patients in the West Australian case study was 48, 15 in the Western Australia exploratory study and 36 in the national study. A number of chiropractic patients participating in this study perceive themselves to be stressed and were interested in having stress-management strategies included in their chiropractic care. Individual patients preferred different stress-management options. This qualitative study found little justification for routinely using a stress-assessment technique more complex than asking the patient to rate his or her stress level as absent, minimal, moderate, or severe. Exercise, particularly walking, was found to be a prevalent pasttime among participants in the case study.

CONCLUSION

This study was too small to warrant statistical analysis; nonetheless, the results of this study are relevant because some patients believe they would benefit from chiropractic care that includes information about stress-management strategies.

Stress: the chiropractic patients' self-perceptions

BACKGROUND

Psychosocial stress pervades modern life and is known to have an impact on health. Pain, especially chronic back pain, is influenced by stress. Various strategies have been shown to successfully reduce stress and its consequences.

OBJECTIVES

This study explores stress as a potential disease trigger among chiropractic patients.

METHOD

A descriptive study was undertaken to ascertain the stress perceptions of chiropractic patients. Purposive sampling of chiropractic practices and convenience sampling of patients was undertaken. Patients were allocated to 1 of 4 groups according to their presentation: acute, chronic biomechanical, fibromyalgia, or maintenance care. Participating patients were requested to complete a questionnaire.

RESULTS

Of the 138 patients attending 1 of 10 participating chiropractic clinics, more than 30% regarded themselves as moderately to severely stressed, and over 50% felt that stress had a moderate or greater effect on their current problem. Some 71% of patients felt it would be helpful if their chiropractic care included strategies to help them cope with stress, and 44% were interested in taking a self-development program to enhance their stress management skills.

CONCLUSION

Patient perceptions are known to be important in health care. A number of chiropractic patients perceive they are moderately or severely stressed. Interventions that reduce stress, or even the patient's perception of being stressed, may be construed as valid, non-specific clinical interventions. It may be timely for chiropractors to actively contemplate including stress management routinely in their clinical care protocols.

Chronicity of back problems during working life

STUDY DESIGN

A follow-up study of a cohort of 444 patients aged 16 to 59 years who consulted with their general practitioners (GPs) in 1987-1988 for an incident episode of back pain.

OBJECTIVES

To determine the proportion of patients with back pain in whom chronic back problems develop after a follow-up of 7 years, to compare health outcomes and labor force participation of patients with and without chronic back problems and to identify determinants of chronicity.

SUMMARY OF BACKGROUND DATA

The incidence and prevalence of back pain are very high. A large proportion of the costs related to medical consumption, absence from work, and disability are probably caused by chronic back problems. It is unknown what proportion of back problems become chronic, especially after a long follow-up period, and which factors can predict chronicity.

METHODS

Data on the course of the symptoms and medical consumption from the period between 1987-1988 and 1991 were gathered retrospectively. Data on several health outcomes, including LFP, and data on some work characteristics were collected prospectively in 1991. A more extensive data set on health outcomes including psychologic status and working situation was collected in 1994.

RESULTS

Chronic back problems developed in 28% of the patients. These patients reported more pain, higher levels of medical resource consumption, worse health outcomes, and lower labor force participation. Episodes of back pain before 1987-1988, severe pain in 1991, and disability score in 1991 were positively associated with chronicity in 1994, difficulties with job performance in 1991, and frequent stooping in the subgroup of patients who held a paying job in the follow-up period.

CONCLUSIONS

Even after a follow-up of 7 years, the proportion of people with chronic back problems was high. The consequences for quality of life, labor force participation, and consumption of medical resources are clear. Further research is necessary to examine determinants and ways to prevent chronicity.

Industrial rehabilitation medicine. 1. Why is industrial rehabilitation medicine unique?

This self-directed learning module is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Industrial rehabilitation medicine encompasses injuries and illnesses that occur in the workplace and are covered under workers' compensation. The central thesis of this article is that industrial rehabilitation medicine is a unique area because the workers' compensation system influences the behavior of injured workers. The article is divided into three sections. The first briefly reviews the history of workers' compensation in the United States, and describes eight key features of compensation systems. The second explores several hypotheses to explain why injured workers frequently have less favorable outcomes than noncompensation patients with similar medical conditions. Some explanations focus on dysfunctional psychologic reactions such as "compensation neurosis" and "disability syndrome." Others focus on contextual factors, including return to work policies by employers and financial incentives or disincentives for return to work. The third section outlines reasons why the physiatrist is often the "preferred provider" in industrial rehabilitation medicine. One crucial consideration is that many of the most important disabling work injuries are those with which physiatrists are familiar. Also, physiatric training and philosophy prepare the physician to focus on function, to work with a rehabilitation team, and to be sensitive to psychologic factors that might impede an injured worker's recovery. All of these skills are important in the treatment of injured workers.

Can psychological traits predict the outcome of lumbar disc surgery when anamnestic and physiological risk factors are controlled for? Results of a prospective cohort study

In a prospective study 122 patients with herniated lumbar disc pre-operatively completed psychological questionnaires. Surgical outcome was evaluated 12 months post-operatively mainly by a composite clinical overall score (COS), and by its separate elements. Anxiety (HAD-A scale) and psychosomatic symptoms (MSPQ) had predictive value: fewer symptoms favoured a satisfactory overall outcome, and vice versa. The HAD-A Scale had a predictive power of poor (ppp) and satisfactory (pps) outcome of 28 and 81%, respectively. Correspondingly, for the MSPQ, the ppp and pps were 42 and 85%. Anamnestic and biological variables (including fibrinolytic variables: ECLT and PAI-1) predicted 20% of the outcome. By adding all psychological variables the prediction increased only to 24%, but the HAD-A Scale and the MSPQ were still significant. The results suggest that in order to further improve prediction of outcome, future studies should combine biological variables sensitive to the mental state of the patient, with psychometric assessments.