Psychological aspects of pain

Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

BACKGROUND

Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope.

OBJECTIVE

To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress.

METHODS

A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically.

RESULTS

3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management.

CONCLUSION

While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.

Experiential Avoidance as a Factor in Generalized Psychological Vulnerability: In the Relationship Between Chronic Pain and Pain Anxiety With Pain Disability

BACKGROUND

Pain is a major socio-psychological problem worldwide. Chronic pain has a negative effect on areas of psychological functioning such as depression, anxiety, and perceived stress.

AIM

The present study investigated the mediating role of experiential avoidance in the relationship between chronic pain and pain anxiety with pain disability.

METHODS

Participants were treatment-seeking patients (N = 361) at an outpatient pain clinic in Shiraz (Fars, Iran). The Multidimensional Pain Inventory (MPI), Pain Anxiety Symptom Scale (PASS-20), Pain Disability Questionnaire (PDQ), and Acceptance and Action Questionnaire-II (AAQ-II) were used to measure multidimensional pain, anxiety, pain disability, experiential avoidance, and pain severity.

RESULTS

The results of the correlation revealed that a significant relationship exists between multidimensional pain and pain anxiety, pain disability, and experiential avoidance. Experiential avoidance mediated the associations from multidimensional pain and pain disability significantly. Also, experiential avoidance moderated associations between pain anxiety and pain disability significantly. In general, Structural Equation Modeling (SEM) showed that experiential avoidance mediated the relationship between multidimensional pain and pain anxiety with pain disability.

CONCLUSION

In general, the results revealed that experiential avoidance can mediate the relationship among pain, pain anxiety, and pain disability as a maladaptive regulation strategy. The results obtained from this study seem to introduce experiential avoidance as a vulnerability factor effectively.

Musculoskeletal Pain in Family Caregivers: Does a Therapeutic Physical Program in Primary Care Work? A Randomized Controlled Trial

Background: Family caregivers play a crucial role in the overall healthcare system and in our society. The elderly population is significantly increasing, which creates a high demand for family caregivers. Few studies have investigated the impact of caregiving on musculoskeletal pain or proposed an active approach for dealing with it. Objectives: To determine and characterize musculoskeletal pain in female family caregivers (FFCs) and assess the effects of adding a therapeutic exercise program to a family caregiver care program (FCCP) on the quality of life, physical conditions, and psychological well-being of FFCs. Methods: A multicenter randomized controlled clinical trial was conducted with 68 FFCs recruited in two public healthcare areas. The intervention and control groups received the same conventional FCCP for 6 h across 4 sessions. The intervention group received an additional 36 sessions of physical therapeutic exercise (PTE) program over 12 weeks. Results: All caregivers reported having pain in particular locations. Lower back pain and neck pain were the locations most frequently cited, with a prevalence of 69.4% and 56.7%, respectively. In total, 80% of participants presented moderate pain intensity. The intervention group showed a significant decrease in the intensity of the pain (p < 0.001), as well as in anxiety, depression, subjective burden perception (p < 0.01), and quality-of-life variables, including MCS (mental component summary) (p < 0.05) and PCS (physical component summary) (p < 0.001). Conclusions: A PTE program improved the musculoskeletal pain of FFCs in a clinically relevant way. The caregivers who improved the most were those who initially presented the most intense pain, had the greatest levels of disability, and had the lowest quality of life.

The effects of neck, core, and combined stabilization practices on pain, disability, and improvement of the neck range of motion in elderly with chronic non-specific neck pain

BACKGROUND: Chronic non-specific neck pain is the most prevalent neck pain with notable impacts on the quality of life in the elderly. OBJECTIVE: The impacts of the neck, core, and combined stabilization practices on pain, disability, and improvement of the neck range of motion in the elderly with chronic non-specific neck pain were examined. METHOD: A quasi-experimental (open label) study was carried out through a cluster sampling in two phases in Tehran-Iran in 2017. Totally, 102 patients were randomly allocated to three groups of specific neck stabilization, specific core stabilization, and combined practices through envelope method. The intervention took 12 weeks. To measure the severity of pain and neck disability, the visual analog scale (VAS), neck disability index (NDI), and neck pain and disability scale (NPDS) was used. A goniometer was used to measure the range of the motion. To examine data, used SPSS (v.20). RESULT: The results, confirmed a significant decrease in pain over the time in the three therapeutic groups (p = 0.000). In addition, there was a significant difference between neck, core, and combined stabilization groups. Moreover, there was a significant increase in the angle of motion in all treatment groups with different treatment duration (P = 0.000). The highest increase in the angle of motion was after 12 weeks of practice in right lateral flexion (RLF) (p = 0.000). CONCLUSION: Twelve sessions of the neck, core, and combined stabilization practices can alleviate the pain and improve the strength in the elderly with chronic non-specific neck pain. In addition, compared to two other methods, the combined method was a more efficient way to improve the range of motion in patients.

The effect of pain management group on chronic pain and pain related co-morbidities and symptoms. A stepped-wedge cluster randomized controlled trial. A study protocol

INTRODUCTION

In primary care settings, pain-management group therapy is a tool potentially cost-effective but very much underused.

METHODS

Our purpose here is to provide useful scientific information on the effect of pain-management group participation on chronic pain and pain-related co-morbidities and symptoms, as well as practical information for primary and occupational health services to initiate pain-management group activity.This study will be carried out at primary care Occupational Health Helsinki (Helsinki city employees' occupational health services), with the Finnish Institute of Occupational Health as the research partner.This is a stepped-wedge cluster randomized controlled trial among both male and female municipal employees aged 18 to 65, all of whom had visited an occupational doctor, nurse, psychologist, or physiotherapist because of any chronic pain unrelated to malignant disease. An additional inclusion criterion is work disability risk being elevated, based on a short screening questionnaire (modified Örebro questionnaire). Each participant and each interviewer will be blinded at randomization. Three groups, 10 subjects in each, begin directly after recruitment with 6 weekly 2-h meetings and a follow-up meeting 6 months later. Three waiting-list groups begin 4 months later. Subjects complete self-administered questionnaires before and after the sixth meetings, also 6 months later. Primary outcomes are pain intensity, current work ability, pain self-efficacy, fear-avoidance beliefs, chronic pain acceptance, depressive symptoms, sleep problems, sickness absence days, and number of occupational health care contacts from OH's medical records.

RESULTS

We will publish our results in a peer-reviewed scientific journals.

The effect of pain management group on chronic pain and pain related co-morbidities and symptoms. A stepped-wedge cluster randomized controlled trial. A study protocol

INTRODUCTION

In primary care settings, pain-management group therapy is a tool potentially cost-effective but very much underused.

METHODS

Our purpose here is to provide useful scientific information on the effect of pain-management group participation on chronic pain and pain-related co-morbidities and symptoms, as well as practical information for primary and occupational health services to initiate pain-management group activity.This study will be carried out at primary care Occupational Health Helsinki (Helsinki city employees' occupational health services), with the Finnish Institute of Occupational Health as the research partner.This is a stepped-wedge cluster randomized controlled trial among both male and female municipal employees aged 18 to 65, all of whom had visited an occupational doctor, nurse, psychologist, or physiotherapist because of any chronic pain unrelated to malignant disease. An additional inclusion criterion is work disability risk being elevated, based on a short screening questionnaire (modified Örebro questionnaire). Each participant and each interviewer will be blinded at randomization.Three groups, 10 subjects in each, begin directly after recruitment with 6 weekly 2-h meetings and a follow-up meeting 6 months later. Three waiting-list groups begin 4 months later. Subjects complete self-administered questionnaires before and after the sixth meetings, also 6 months later. Primary outcomes are pain intensity, current work ability, pain self-efficacy, fear-avoidance beliefs, chronic pain acceptance, depressive symptoms, sleep problems, sickness absence days, and number of occupational health care contacts from OH's medical records.

RESULTS

We will publish our results in a peer-reviewed scientific journals.

Psychometric Evaluation of the Nursing Outcome "Pain: Adverse Psychological Response" in Patients With Chronic Pain

PURPOSE

To culturally adapt into Spanish and validate the outcome "Pain: Adverse psychological response" (code 1306) in patients with chronic pain.

METHODS

A three-stage study was conducted: (a) translation and cultural adaptation, (b) content validation, and (c) clinical validation.

FINDINGS

The Spanish version of the outcome "Pain: Adverse psychological response" has high content validity ( 0.91). Fourteen indicators were organized into two factors. This version offers good reliability in both inter-observer agreement (kappa = 0.72) and internal consistency (alpha = 0.89).

CONCLUSIONS

The Spanish adaptation of "Pain: Adverse psychological response" is a reliable and valid instrument for the measurement of emotional aspects of chronic pain.

IMPLICATIONS FOR NURSING PRACTICE

The Spanish adaptation of this outcome offers nurses a set of structured indicators to measure the adverse emotional impact of chronic pain.

Influence of significant others on work participation of individuals with chronic diseases: a systematic review

OBJECTIVE

It is widely recognised that significant others (SOs), such as a partner, family member or friend, can influence health outcomes of individuals with a chronic disease. However, not much is known about which specific cognitions (ie, illness perceptions and expectation of work ability) and behaviours (eg, emotional and practical support) of SOs influence work participation. Therefore, we aimed to identify cognitions and behaviours of SOs that are related to work participation of individuals with a chronic disease.

DESIGN

A systematic review and thematic synthesis.

DATA SOURCES

PubMed, Embase, PsycINFO, SocINDEX and Web of Science were searched until 28 March 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies reporting on cognitions and behaviours of SOs related to work participation in populations with various chronic diseases.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the data and performed a quality assessment using the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project 2007 and a checklist for assessment of qualitative studies derived from the Cochrane Supplemental Handbook Guidance. Evidence was thematically synthesised.

RESULTS

Out of 5168 articles, 18 were included (15 qualitative and 3 quantitative) of moderate to high quality. Studies were on cancer, chronic pain, brain injuries and mental health disorders. After thematic synthesis 27 factors could be distinguished. Consistent evidence was found that SOs' positive and encouraging attitudes regarding work participation, encouragement and motivating behaviour and open communication with patients are facilitators for work participation. Consistently reported barriers were SOs' positive attitudes towards sickness absence and advise, encouragement or pressure to refrain from work.

CONCLUSIONS

Our findings show that several cognitions and behaviours of SOs can facilitate or hinder work participation of individuals with a chronic disease. Intervening on these factors by involving SOs in disability prevention and return to work intervention strategies may be beneficial. More prognostic studies are needed, as the current evidence is mostly based on qualitative studies.

Application of algometry in patients with cervical and lumbar radiculopathy

BACKGROUND

Algometry, as a highly sensitive method, provides an objective insight into the degree of pain, while the use of questionnaires can estimate the patient's psychological status in a simple way.

OBJECTIVE

This study was conducted in order to measure the pressure pain threshold in patients with cervical and lumbar radiculopathy and to find a possible association of pain with the anxiety and depression.

METHODS

The study examined 60 hospitalized patients with cervical radiculopathy and 60 patients with lumbar radiculopathy before starting and after finishing kinesitherapy. The research was conducted using the digital algometry device and Hospital Anxiety and Depression Scale.

RESULTS

There was no statistically significant difference in algometric values between the patients with cervical radiculopathy and the patients with lumbar radiculopathy. The program of rehabilitation did not lead to significant improvement in the level of pain. Females have a lower pressure pain threshold than males. Psychological factors greatly affect the pain.

CONCLUSIONS

The applied methods will provide the implementation of appropriate therapy and would achieve better verification of the results in a rehabilitation program. Radiculopathy in conservative therapy should be treated in cervical-thoracic and lumbar region together. Rehabilitation period for patients with radiculopathy have to be longer.

The use of an e-learning module on return to work advice for physiotherapists - A prospective cohort study

Background: Nonspecific low back pain (LBP) can progress to chronic disability and prolonged absence from work. Despite clinical and professional guidelines, physiotherapists often fail to address return to work outcomes. Aims: The aim of this exploratory study was to determine whether an e-learning resource tailored to physiotherapy practice could affect physiotherapists' attitudes and beliefs regarding return to work advice for their patients. Design: A prospective interventional cohort study (pilot). Methods: Participants were recruited via the Chartered Society of Physiotherapy website. Responses on a clinical vignette, the Health Care Providers' Pain and Impairment Scale (HC-Pairs), and the Behavioral Constructs Questionnaire (BCQ) were collected online at baseline (Q1) and 2-months post-intervention (Q2). Results: Fifty-four physiotherapists completed Q1 and the response rate for Q2 was 44/54 (81%). Changes in the degree of agreement with guidelines indicated that the intervention made an impact on respondents (kappa 0.345; p = 0.003). HC-Pairs and BCQ results showed a nonstatistically significant trend toward the target behavior. Conclusions: There is a need for interventions to improve adherence with advice for return to work following nonspecific LBP. An e-learning tool for physiotherapists on advising patients regarding return to work has potential to positively affect self-reported clinical behavior.

Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review

BACKGROUND

Chronic peripheral joint pain due to osteoarthritis (OA) is extremely prevalent and a major cause of physical dysfunction and psychosocial distress. Exercise is recommended to reduce joint pain and improve physical function, but the effect of exercise on psychosocial function (health beliefs, depression, anxiety and quality of life) in this population is unknown.

OBJECTIVES

To improve our understanding of the complex inter-relationship between pain, psychosocial effects, physical function and exercise.

SEARCH METHODS

Review authors searched 23 clinical, public health, psychology and social care databases and 25 other relevant resources including trials registers up to March 2016. We checked reference lists of included studies for relevant studies. We contacted key experts about unpublished studies.

SELECTION CRITERIA

To be included in the quantitative synthesis, studies had to be randomised controlled trials of land- or water-based exercise programmes compared with a control group consisting of no treatment or non-exercise intervention (such as medication, patient education) that measured either pain or function and at least one psychosocial outcome (self-efficacy, depression, anxiety, quality of life). Participants had to be aged 45 years or older, with a clinical diagnosis of OA (as defined by the study) or self-reported chronic hip or knee (or both) pain (defined as more than six months' duration).To be included in the qualitative synthesis, studies had to have reported people's opinions and experiences of exercise-based programmes (e.g. their views, understanding, experiences and beliefs about the utility of exercise in the management of chronic pain/OA).

DATA COLLECTION AND ANALYSIS

We used standard methodology recommended by Cochrane for the quantitative analysis. For the qualitative analysis, we extracted verbatim quotes from study participants and synthesised studies of patients' views using framework synthesis. We then conducted an integrative review, synthesising the quantitative and qualitative data together.

MAIN RESULTS

Twenty-one trials (2372 participants) met the inclusion criteria for quantitative synthesis. There were large variations in the exercise programme's content, mode of delivery, frequency and duration, participant's symptoms, duration of symptoms, outcomes measured, methodological quality and reporting. Comparator groups were varied and included normal care; education; and attention controls such as home visits, sham gel and wait list controls. Risk of bias was high in one and unclear risk in five studies regarding the randomisation process, high for 11 studies regarding allocation concealment, high for all 21 studies regarding blinding, and high for three studies and unclear for five studies regarding attrition. Studies did not provide information on adverse effects.There was moderate quality evidence that exercise reduced pain by an absolute percent reduction of 6% (95% confidence interval (CI) -9% to -4%, (9 studies, 1058 participants), equivalent to reducing (improving) pain by 1.25 points from 6.5 to 5.3 on a 0 to 20 scale and moderate quality evidence that exercise improved physical function by an absolute percent of 5.6% (95% CI -7.6% to 2.0%; standardised mean difference (SMD) -0.27, 95% CI -0.37 to -0.17, equivalent to reducing (improving) WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) function on a 0 to 100 scale from 49.9 to 44.3) (13 studies, 1599 participants)). Self-efficacy was increased by an absolute percent of 1.66% (95% CI 1.08% to 2.20%), although evidence was low quality (SMD 0.46, 95% CI 0.34 to 0.58, equivalent to improving the ExBeliefs score on a 17 to 85 scale from 64.3 to 65.4), with small benefits for depression from moderate quality evidence indicating an absolute percent reduction of 2.4% (95% CI -0.47% to 0.5%) (SMD -0.16, 95% CI -0.29 to -0.02, equivalent to improving depression measured using HADS (Hospital Anxiety and Depression Scale) on a 0 to 21 scale from 3.5 to 3.0) but no clinically or statistically significant effect on anxiety (SMD -0.11, 95% CI -0.26 to 0.05, 2% absolute improvement, 95% CI -5% to 1% equivalent to improving HADS anxiety on a 0 to 21 scale from 5.8 to 5.4; moderate quality evidence). Five studies measured the effect of exercise on health-related quality of life using the 36-item Short Form (SF-36) with statistically significant benefits for social function, increasing it by an absolute percent of 7.9% (95% CI 4.1% to 11.6%), equivalent to increasing SF-36 social function on a 0 to 100 scale from 73.6 to 81.5, although the evidence was low quality. Evidence was downgraded due to heterogeneity of measures, limitations with blinding and lack of detail regarding interventions. For 20/21 studies, there was a high risk of bias with blinding as participants self-reported and were not blinded to their participation in an exercise intervention.Twelve studies (with 6 to 29 participants) met inclusion criteria for qualitative synthesis. Their methodological rigour and quality was generally good. From the patients' perspectives, ways to improve the delivery of exercise interventions included: provide better information and advice about the safety and value of exercise; provide exercise tailored to individual's preferences, abilities and needs; challenge inappropriate health beliefs and provide better support.An integrative review, which compared the findings from quantitative trials with low risk of bias and the implications derived from the high-quality studies in the qualitative synthesis, confirmed the importance of these implications.

AUTHORS' CONCLUSIONS

Chronic hip and knee pain affects all domains of people's lives. People's beliefs about chronic pain shape their attitudes and behaviours about how to manage their pain. People are confused about the cause of their pain, and bewildered by its variability and randomness. Without adequate information and advice from healthcare professionals, people do not know what they should and should not do, and, as a consequence, avoid activity for fear of causing harm. Participation in exercise programmes may slightly improve physical function, depression and pain. It may slightly improve self-efficacy and social function, although there is probably little or no difference in anxiety. Providing reassurance and clear advice about the value of exercise in controlling symptoms, and opportunities to participate in exercise programmes that people regard as enjoyable and relevant, may encourage greater exercise participation, which brings a range of health benefits to a large population of people.

Are determinants for new and persistent upper limb pain different? An analysis based on anatomical sites

BACKGROUND

Only few longitudinal studies have explored separately predictors of pain incidence and persistence.

OBJECTIVE

To investigate whether biological, lifestyle, occupational and psychological risk factors for the development of new episodes of upper limb pain (ULP) differ from those for its persistence.

METHODS

Spanish nurses and office workers (1105) were asked at baseline about biological, lifestyle, occupational and psychological risk factors and pain in the past month at six anatomical sites in the upper limb (left and right shoulder, elbow and wrist/hand). At follow up, 12 months later, pain in the past month was again ascertained. Analysis was based on anatomical sites clustered by person. Associations were assessed by multilevel logistic regression models.

RESULTS

Nine hundred and seventy-one participants (87.9%) completed follow-up. Job dissatisfaction and older age carried higher risk of new ULP. Somatising tendency (OR 2.2, 95% CI 1.6-3.1) was the strongest predictor of new ULP, with a risk estimate which differed significantly from that for the same exposure and persistence of ULP. Having adverse beliefs about the work-relatedness of ULP carried a significantly reduced risk for persistence of ULP.

CONCLUSION

Our study provides only limited evidence that risk factors predicting new ULP differ from those predicting its persistence.

Predictors of Early Postoperative Pain After Photorefractive Keratectomy

PURPOSE

To compare the profiles of postoperative photorefractive keratectomy (PRK) pain between both eyes under the same conditions and to verify the preoperative predictors of pain such as gender, anxiety, knowledge of the procedure, and spherical equivalent refractive error (SERE).

METHODS

This prospective study included 86 eyes of 43 patients with myopia who underwent PRK in both eyes at an interval of 14 days between the procedures. Before surgery, subjects answered the State Anxiety Inventory. After surgery, usual PRK pain treatment was given. Subjects answered the Visual Analog Scale, the Brief Pain Inventory (BPI), and the McGill Pain Questionnaire at 1, 24, 48, 72, and 96 hours after surgery. Pain scores and anxiety were compared between each eye using the Wald test and paired Student t test, respectively. The Wald test was performed for gender and SERE for each eye separately.

RESULTS

There were no statistically significant differences between both eyes for all time points regarding the Visual Analog Scale, BPI, and McGill Pain Questionnaire-Pain Rating Index pain scores. Subjects were less anxious on average before the second surgery compared with before the first surgery (P < 0.001); however, it was not related to pain ratings after surgery. Gender did not significantly affect any scale of pain, and the SERE between -3 diopters (D) and -5 D (P = 0.035) revealed effects on the BPI.

CONCLUSIONS

The profiles of postoperative pain after PRK were similar between both eyes under the same conditions. In this study, a high SERE was the only predictor for increased pain after PRK.

'I think positivity breeds positivity': a qualitative exploration of the role of family members in supporting those with chronic musculoskeletal pain to stay at work

Background

It is proposed that family members are important sources of support in helping those with chronic musculoskeletal pain to remain at work, but the phenomenon remains largely unexplored. The aim of this study was to examine the extent and nature of support provided by family members in this respect.

Methods

Qualitative data were collected from workers and their ‘significant others’ (spouses/partners/close family members) in two un-related studies focused on working with pain; one conducted in the United Kingdom (n = 10 dyads) and one in the Netherlands (n = 21 dyads). Thematic analysis techniques were applied to both sets of data independently, and findings were then assimilated to establish common themes.

Results

Findings were broadly similar in both studies. Workers acknowledged significant other support in helping them to manage their pain and remain at work, and their descriptions of the type of support provided and required were echoed by their significant others. Three common themes were identified - ‘connectivity’, ‘activity’ and ‘positivity’. Worker and significant other responses were largely congruent, but significant others provided more in-depth information on the nature of their support, their concerns and the impact on their relationship.

Conclusions

This research presents novel insights about the specific contribution made by significant others in helping their relatives with chronic musculoskeletal pain to stay at work. These findings add to the under-represented ‘social’ dimension of the biopsychosocial model currently applied to our understanding and treatment of pain, and point to harnessing support from significant others as a potentially effective management strategy.

The usefulness of clinical measures of psychologic factors in patients with spinal pain

OBJECTIVE

The purposes of this study were to investigate whether a screening procedure could capture important psychologic factors with minimum burden to the patient and to investigate whether correlations exist among the various psychologic factors.

METHODS

A screening procedure consisting of the 11-item Tampa Scale for Kinesiophobia, a 2-question coping strategies screen, and the depression and anxiety subscales of the Bournemouth Disability Questionnaire was provided to consecutive patients with neck pain (NP) or low back pain (LBP) as part of the usual initial assessment process at a busy spine center, which includes chiropractic and physical therapy. Correlations and associations between these variables were determined.

RESULTS

Data were collected on 95 patients with NP and 260 patients with LBP. Statistically significant correlations and associations were found between all measures in both cohorts with the exception of depression and coping in patients with NP. Statistically significant associations were found among all measures in both cohorts with the exception of depression and coping and coping and fear in patients with NP.

CONCLUSION

This study showed that a screening procedure may provide useful clinical information regarding psychologic factors that are of potential relevance in patients with NP and LBP.

Simulation tests for cervical nonorganic signs: a study of face validity

OBJECTIVES

The purpose of this study was to develop and determine the face validity of additional cervical nonorganic simulation tests.

METHODS

Four simulation tests were either selected from the literature or newly designed: simulated sitting trunk/shoulder rotation (SR; test no. 1), active vs passive cervical rotation (CR; test no. 2), Libman's test (LT; test no. 3) of pressure over the mastoid process, and side-lying passive shoulder abduction (SA; test no. 4). Three groups, 1 without neck pain (n = 44) and 2 with neck pain (n = 43 and 27), were formed. Outcome measures consisted of questions on provocation of pain (Yes/No) and appropriateness (Yes/No) as well as measurements of cervical rotation (goniometric) and pressure pain threshold (pressure algometer). Group test responses were evaluated and scored. A threshold of acceptance was established at 80% agreement for face validity. Ranges of rotation and pressure threshold values were analyzed with the Student t test.

RESULTS

In nonneck pain subjects, all 4 tests were rated as nonpainful and 3 were rated as "appropriate" for neck pain examination (not SR). In neck pain subjects, this test and SA were rated as nonpainful, whereas LT was rated as painful in 26% of subjects. Only CR and LT were rated as "appropriate." In neck pain subjects, passive rotations exceeded actives by 10% to 14% (P = .000). On a second round of testing with a slightly modified method, SR and SA achieved acceptable "appropriateness."

CONCLUSIONS

Once 2 tests were slightly modified, all 4 tests were found to have acceptable face validity. Further research into the reliability of these tests as well as into the combinations of these tests is warranted.

Psychological factors in the use of the neck disability index in chronic whiplash patients

STUDY DESIGN

Cross-sectional clinical study.

OBJECTIVE

Determine if psychological factors "fear avoidance behavior" and "pain amplification," along with age, gender, duration, and pain severity correlate with scores of self-rated disability in chronic whiplash sufferers.

SUMMARY OF BACKGROUND DATA

The Fear Avoidance Model has gained acceptance in the understanding of whiplash-associate disorders (WAD). While the variables important in this model have been studied in acute/subacute samples and some small chronic samples, no study has explicitly investigated the role these and other psychosocial variables play in the self-ratings of neck-related disability in chronic WAD sufferers.

METHODS

Chronic WAD sufferers (>3 months) were recruited from private practice. No WAD IV subjects were included. Subjects completed a Neck Disability Index (NDI), Tampa Scale for Kinesiophobia (TSK), pain visual analogue scale, and pain diagram. Clinical and demographic data were also obtained. Univariate correlations were obtained with the Spearman rank correlation coefficient. Items achieving statistical significance on univariate analysis were loaded in a step-wise linear regression analysis.

RESULTS

One hundred seven subjects were investigated (54 females), with a mean age of 45.4 (17) years and a mean duration of 13.4 (14.6) months. Fair to moderately strong correlations were obtained between the NDI and the TSK, pain visual analogue scale and pain drawing scores, but not with "duration." The Pain Diagram correlated with NDI scores and pain severity. A multivariate model accounting for 31% of the variance of the NDI scores (P < 0.001) was obtained with the TSK, pain severity, and pain drawing.

CONCLUSION

It appears that important psychological factors (fear avoidance beliefs and pain amplification) do have some influence on self-ratings of disability in chronic WAD sufferers. This does not appear to be larger than that found in studies of acute/subacute subjects. The influence of these factors may plateau fairly early in the post-WAD period. There is some evidence that the Pain Diagram may provide insight into nonorganic pain behavior.

Understanding pain in osteoarthritis

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.

How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists

Guidelines for the management of low back pain (LBP) have existed for many years, but adherence to these by health care practitioners (HCPs) remains suboptimal. The aim of this study was to measure the attitudes, beliefs and reported clinical behaviour of UK physiotherapists (PTs) and general practitioners (GPs) about LBP and to explore the associations between these. A cross-sectional postal survey of GPs (n=2000) and PTs (n=2000) was conducted that included the Pain Attitudes and Beliefs Scale (PABT.PT), and a vignette of a patient with non-specific LBP (NSLBP) with questions asking about recommendations for work, activity and bedrest. Data from 1022 respondents (442 GPs and 580 PTs) who had recently treated patients with LBP were analysed. Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations, 28% reported they would advise this patient to remain off work. Work advice was significantly related to the PABS.PT scores with higher biomedical (F(1,986)=77.5, p<0.0001) and lower behavioural (F(1,981)=31.9, p<0.001) scores associated with advice to remain off work. We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse. Many HCPs held the belief that LBP necessitates some avoidance of activities and work. The attitudes and beliefs of these HCPs were associated with their self-reported clinical behaviour regarding advice about work. Future studies need to investigate whether approaches aimed at modifying these HCP factors can lead to improved patient outcomes.

Chronic non-specific low back pain - sub-groups or a single mechanism?

BACKGROUND

Low back pain is a substantial health problem and has subsequently attracted a considerable amount of research. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific low back pain indicate limited effectiveness for most commonly applied interventions and approaches.

DISCUSSION

Many clinicians challenge the results of clinical trials as they feel that this lack of effectiveness is at odds with their clinical experience of managing patients with back pain. A common explanation for this discrepancy is the perceived heterogeneity of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient. An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. Preoccupation with sub-grouping may stifle engagement with this view and it is important that the sub-grouping paradigm is closely examined. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials. We propose instead that current treatment may be ineffective because it has been misdirected. Recent evidence that demonstrates changes within the brain in chronic low back pain sufferers raises the possibility that persistent back pain may be a problem of cortical reorganisation and degeneration. This perspective offers interesting insights into the chronic low back pain experience and suggests alternative models of intervention.

SUMMARY

The disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population. Alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed.

Interventions for treating the radial tunnel syndrome: a systematic review of observational studies

PURPOSE

For some disorders, such as radial tunnel syndrome (RTS), no randomized controlled trials and controlled clinical trials are available. To gain insight into the effectiveness of conservative and surgical interventions for treating RTS, we systematically reviewed all available observational studies on treatment of RTS. Although the validity of case series is inferior to that of controlled trials, the case series might provide valuable data about the efficacy of treatment options.

METHODS

A literature search and additional reference checking resulted in 21 eligible case series for this review. Based on previous checklists, we constructed a new quality assessment and rating system to analyze the included case series. The methodological quality was assessed, and data extraction was performed. Studies with less than 50% of the maximum points on the methodological quality assessment were considered inadequate and were excluded from the analysis. To summarize the results according to the rating system for the strength of the scientific evidence for these case series, we introduced 4 levels: (1) tendency, (2) slight tendency, (3) conflicting tendency, and (4) no tendency.

RESULTS

After the methodological quality assessment, 6 articles were included in the final analysis. They all reported on surgical treatment.

CONCLUSIONS

There is a tendency that surgical decompression of the radial tunnel might be effective in patients with RTS. The effectiveness of conservative treatments for RTS is unknown because, for most treatments, no studies were available. Additional high-quality controlled studies are needed to assess the level of conclusive evidence for surgical treatment and also to evaluate conservative treatments for RTS. For this, we recommend a multicenter, randomized clinical trial. Due to the lack of a clear protocol for diagnosing RTS, a reliable and valid diagnostic tool should be developed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A comparison of manual therapy and active rehabilitation in the treatment of non specific low back pain with particular reference to a patient's Linton & Hallden psychological screening score: a pilot study

Background

Clinical guidelines for the management of back pain frequently recommend 'manual therapy' as a first line intervention, with psychosocial screening and 'active rehabilitation' for those not improving at 6 weeks post onset. The potential for psychosocial factors to predict treatment response and therefore outcome has not been adequately explored. The purpose of this pilot study was to determine the feasibility of a study to compare manual therapy and active rehabilitation outcomes for subjects with sub-acute/chronic back pain, investigate whether any difference in outcome was related to psychosocial factors, and to inform the design of a main study.

Methods

A convenience sample of 39 patients with non-specific low back pain referred to the physiotherapy department of an acute NHS Trust hospital was recruited over a nine month period. Patients completed the Linton and Hallden psychological screening questionnaire (LH) and were allocated to a low LH (105 or below) or high LH (106 or above) scoring group. The low or high LH score was used to sequentially allocate patients to one of two treatment groups – Manual Therapy comprising physiotherapy based on manual means as chosen by the treating therapist or Active Rehabilitation comprising a progressive exercise and education programme – with the first low LH scoring patient being allocated to active rehabilitation and the next to manual therapy and so on. Treatment was administered for eight sessions over a four-week period and outcome measures were taken at baseline and at four weeks. Measures used were the Roland Morris Questionnaire (RMQ), two components of the Short Form McGill (total pain rating index [PRI] and pain intensity via visual analogue scale [VAS]), and the LH.

Results

The manual therapy group demonstrated a greater treatment effect compared with active rehabilitation for RMQ (mean difference 3.6, 95% CI 1.1 – 6.2, p = 0.006) and PRI (7.1, 95% CI 2.0 – 12.2, p = 0.007) and marginally significant results for VAS (15, 95% CI -1.1 to 31.2, p = 0.067). A linear model allowing for confounding effects and the interaction between high or low LH scores supported these results. The interaction effect was not significant for any outcome measure but this could be due to an insufficient number of subjects to detect this effect.

Conclusion

Comparative evaluation of manual therapy and active rehabilitation with reference to LH psychosocial scores is likely to be detectable by the methods used here. However several alterations to the study design are recommended for the main study. A pragmatic trial using a randomisation process with stratification on the LH score and priori power analysis to determine sample size are suggested for the main study.

The development and use of mass media interventions for health-care messages about back pain: What do members of the public think?

The study sought to identify and explore the opinions, beliefs and views of members of the public regarding the use of media interventions for the delivery of health-care messages. It used a draft back pain campaign looking at the level of credibility, acceptability and trust in the authority of these messages. Sixty-eight members of the public participated in the study. A qualitative study design was used with semi-structured focus groups and a sampling frame including gender, age, socio-economic group, and experience of back pain. Three main themes were identified. 1. Media consumption. 2. Credibility. 3. Specific issues surrounding the proposed sample media campaign. The use of media to provide health-care information was viewed positively, with the NHS perceived as the most trustworthy source, and Government bodies viewed with scepticism. Issues surrounding the language, terminology and tone of campaigns were raised. A closer collaboration between health-care professionals and the public is advocated to achieve valuable and effective media campaigns.

Diagnosis and classification of pelvic girdle pain disorders--Part 1: a mechanism based approach within a biopsychosocial framework

The diagnosis and classification of pelvic girdle pain (PGP) disorders remains controversial despite a proliferation of research into this field. The majority of PGP disorders have no identified pathoanatomical basis leaving a management vacuum. Diagnostic and treatment paradigms for PGP disorders exist although many of these approaches have limited validity and are uni-dimensional (i.e. biomechanical) in nature. Furthermore single approaches for the management of PGP fail to benefit all. This highlights the possibility that 'non-specific' PGP disorders are represented by a number of sub-groups with different underlying pain mechanisms rather than a single entity. This paper examines the current knowledge and challenges some of the common beliefs regarding the sacroiliac joints and pelvic function. A hypothetical 'mechanism based' classification system for PGP, based within a biopsychosocial framework is proposed. This has developed from a synthesis of the current evidence combined with the clinical observations of the authors. It recognises the presence of both specific and non-specific musculoskeletal PGP disorders. It acknowledges the complex and multifactorial nature of chronic PGP disorders and the potential of both the peripheral and central nervous system to promote and modulate pain. It is proposed that there is a large group of predominantly peripherally mediated PGP disorders which are associated with either 'reduced' or 'excessive' force closure of the pelvis, resulting in abnormal stresses on pain sensitive pelvic structures. It acknowledges that the interaction of psychosocial factors (such as passive coping strategies, faulty beliefs, anxiety and depression) in these pain disorders has the potential to promote pain and disability. It also acknowledges the complex interaction that hormonal factors may play in these pain disorders. This classification model is flexible and helps guide appropriate management of these disorders within a biopsychosocial framework. While the validity of this approach is emerging, further research is required.

Evaluation of variations in sensory and pain threshold assessments by electrocutaneous stimulation

Assessed sensory and pain thresholds can change consequently to disturbances associated with ongoing pain. Such assessments could be an additional method in the daily clinical evaluation of perceived pain. To study the test-retest variability within-day and between-day of such procedures a newly developed instrument producing electrocutaneous stimulation, PainMatcher (PM), was used to assess the electrical sensory thresholds (EST) and pain thresholds (EPT) in healthy volunteers and in patients with pain. The produced data were considered ordinal and analyzed with rank-invariant statistics with properties of analyzing systematic disagreement, bias, and individual variations. The percentage agreements within +/- 1PM value for EST were in the two groups of healthy volunteers and patients in pain 94% and 92%, and for EPT assessments 49% and 78%, respectively. The variability in the EST assessments is possibly explained by a slight bias while the individual variations were negligible between the two occasions. The assessed EPT were unbiased in both groups while individual variations were significant among the healthy volunteers but negligible among the patients in pain. The EST was found to be increased in pain patients compared to healthy volunteers, p < 0.03, and the EPT decreased in pain patients compared to healthy volunteers, p < 0.001. The results in this study indicate stable and reliable assessments of EST and EPT except for a possible bias. The threshold assessment procedure followed in this study may be a valuable tool in the clinical evaluation of sensory and pain assessments in pain patients.

Self-Report and Pain Behavior Among Patients With Chronic Pain

OBJECTIVES

To determine the relationship between pain behaviors and self-report of pain and disability in patients with chronic pain.

METHODS

Thirty-nine patients (59% women), aged 19 to 79 years, admitted to a Multidisciplinary Pain Center with chronic noncancer pain, were assessed on the following: 1) pain intensity using a 0 to 10 Numerical Graphic Rating Scale; 2) the Pain Disability Index; 3) the Pain Self-Efficacy Questionnaire; 4) a 10-minute videotaped session involving sitting, standing, walking, and reclining, after which pain behaviors were coded using a standardized observational protocol.

RESULTS

Interrelationships among pain intensity, pain disability, self-efficacy, and pain behavior were tested using the Pearson product-moment correlations. Significant relationships were found between pain behavior frequencies and self-reported pain intensity (r = 0.29, P < 0.05), self-reported pain disability (r = 0.54, P < 0.0005), and reported self-efficacy (r = -0.42, P < 0.005). Multiple regression analyses were performed to further investigate these interrelationships. Only the Pain Disability Index score was found to make a significant unique contribution (semipartial correlation of 15%, P < 0.008) to the prediction of total pain behavior score.

DISCUSSION

Findings suggest that pain behavior observation is a valid and reliable assessment tool for use with a heterogeneous chronic pain population. Significant associations were found between pain behaviors and self-report measures of pain intensity, pain disability, and self-efficacy; pain intensity scores displayed a weak relationship; and pain disability scores the strongest relationship with pain behavior. Viewed with previous research, the results of this study indicate the value of a multimodal, cognitive-behavioral approach to assessing patients with chronic pain.

Test-Retest Reliability of the Short-Form McGill Pain Questionnaire

OBJECTIVES

No previous study has adequately demonstrated the test-retest reliability of the Short-Form McGill Pain Questionnaire, yet it is increasingly being used as a measure of pain. This study evaluates the test-retest reliability in patients with osteoarthritis.

METHODS

A prospective, observational cohort study was undertaken using serial evaluation of 57 patients at 2 time points. A sample of patients awaiting primary hip or knee joint replacement surgery were recruited in clinic or via mail (mean age 64.8 years). Short-Form McGill Pain Questionnaires were delivered by mail 5 days apart, and a supplementary questionnaire was completed on the second occasion to explore if the patients' pain report had remained stable.

RESULTS

The intraclass correlation coefficient was used as an estimate of reliability. For the total, sensory, affective, and average pain scores, high intra-class correlations were demonstrated (0.96, 0.95, 0.88, and 0.89, respectively). The current pain component demonstrated a lower intraclass correlation of 0.75. The coefficient of repeatability was calculated as an estimation of the minimum metrically detectable change. The coefficients of repeatability for the total, sensory, affective, average, and current pain components were 5.2, 4.5, 2.8, 1.4 cm, and 1.4, respectively.

DISCUSSION

Problems of adequate completion of the Short-Form McGill Pain Questionnaire were highlighted in this sample, and supervision via telephone contact was required. Patients recruited in clinic who had practiced completing the Short-Form McGill Pain Questionnaire demonstrated fewer errors than those recruited by mail. The Short-Form McGill Pain Questionnaire was demonstrated to be a highly reliable measure of pain. These results should not be generalized to a more elderly population, as increasing age was correlated with greater variability of the sensory component scores.

Physiotherapists' pain beliefs and their influence on the management of patients with chronic low back pain

PURPOSE

Little is known about physiotherapists' pain beliefs and whether they influence behavior within therapeutic encounters with patients. This qualitative study explored physiotherapists' pain beliefs with the purpose of highlighting the nature of their beliefs and the role they played within their management of chronic low back pain.

METHODS

Six physiotherapists were purposefully sampled along with 12 of their patients with chronic low back pain (two patients each). A qualitative exploration of physiotherapists' pain beliefs within the context of a clinical situation was carried out using semistructured interviews and observations at designated stages throughout therapeutic encounters with their patients. The data were prepared and analyzed according to a grounded theory approach.

RESULTS

The themes that emerged from the data indicated that the pain beliefs of physiotherapists in this study were determined by a number of perspectives including their beliefs regarding the development of craft knowledge needed to manage chronic low back pain, beliefs regarding the clinical characteristics of patients with chronic low back pain they considered to be "good" to treat and the challenge of patients who were "difficult" to treat, and pain beliefs within the therapeutic encounter. A tentative theory was developed which proposed that the physiotherapists' biomedically oriented pain beliefs influenced their clinical reasoning processes including the explanations given to the patients.

CONCLUSIONS

The findings suggest that in order to maximize the rehabilitation potential of patients with chronic low back pain, physiotherapists need to be aware that their pain beliefs may influence their management of these patients.

Long-term follow-up of patients with low back pain attending for manipulative care: outcomes and predictors

Psychosocial factors are known to act as obstacles to recovery from low back pain, but predictors of longer-term outcomes are not established. An average 4-year follow-up of a cohort of 252 low back pain patients attending for manipulative care was conducted to describe the longer-term course of low back pain, and to identify predictors of outcomes. Clinical and psychosocial data were obtained at baseline. Mailed questionnaires collected self-reported outcomes (pain, disability, recurrence and care seeking). Among the 60% who responded, the statistically significant reduction in mean Roland Disability Questionnaire score seen at 1 year did not improve further during follow-up. At the 4-year point, 49% of respondents reported residual disability, and 59% reported at least 'mild' pain. Symptom recurrence beyond the 1-year point was reported by 78% of respondents, with half of them seeking further care. Recurrence and care seeking were related to fear avoidance beliefs and duration of presenting symptoms. The disability score at 4-years was statistically significantly related to baseline depressive symptoms and higher pain intensity. Low back pain presenting for manipulative care is characterized by high levels of recurrence and care seeking over at least 4-years for many patients. Because psychosocial factors at presentation exert a long-term influence, they need to be considered by manual therapists.

In osteoarthritis, the psychosocial benefits of exercise are as important as physiological improvements

Exercise has a major role in the management of osteoarthritis, effecting well-documented physiological improvements on muscle function. However, exercise also has lasting benefits on the complex psychosocial sequelae of osteoarthritis--facilitating appropriate health beliefs, behaviors, pain coping, and self-management strategies--that are as important as its physiological effects.

Lumbar repositioning deficit in a specific low back pain population

STUDY DESIGN

A cross-sectional observational design study was conducted to determine lumbar repositioning error in 15 subjects who had chronic low back pain with a clinical diagnosis of lumbar segmental instability and 15 asymptomatic participants.

OBJECTIVE

To determine whether individuals with lumbar segmental instability have a decreased ability to reposition their lumbar spine into a neutral spinal position.

SUMMARY OF BACKGROUND DATA

Proprioception of the lumbar spine has been investigated in individuals who have low back pain with variable results. The testing procedure's lack of sensitivity and the nonhomogeneity of groups may be responsible for the conflicting findings.

METHODS

Repositioning accuracy of the lumbar spine was assessed using the 3Space Fastrak to determine error in 15 participants with lumbar segmental instability and 15 asymptomatic subjects. The participants were assisted into a neutral spinal sitting posture and then asked to reproduce this position independently over five trials separated by periods of relaxed full lumbar flexion.

RESULTS

Lumbosacral repositioning error was significantly greater in participants with lumbar segmental instability than in the asymptomatic group (t[28] = 2.48; P = 0.02. There also was a significant difference between the groups at each individual sensor.

CONCLUSIONS

The results of this study indicate that individuals with a clinical diagnosis of lumbar segmental instability demonstrate an inability to reposition the lumbar spine accurately into a neutral spinal posture while seated. This finding provides evidence of a deficiency in lumbar proprioceptive awareness among this population.