The role of physiotherapy in the management of non-specific back pain and neck pain

Assessing the knowledge of low back pain among physiotherapists in Spain: A cohort study with pre- and post-educational course evaluation

BACKGROUND

Low back pain (LBP) is the most prevalent musculoskeletal disorder worldwide and physiotherapists are among the primary healthcare professionals assessing and treating the condition. However, scientific knowledge regarding the management of LBP amongst physiotherapists is largely unknown.

OBJECTIVES

To evaluate the level of evidence-based knowledge among Spanish physiotherapists in LBP management and assess knowledge enhancement following the completion of an e-learning course.

DESIGN

Single-arm cohort study with pre-post evaluation.

METHODS

This single-arm pre-post study involved 1350 physiotherapists practicing in Spain. Initially, participants underwent a 22-question test on evidence-based LBP knowledge, covering socio-economic impact, characteristics of LBP, rehabilitation goals, psychosocial factors, and high- and low-value interventions. After completing the course, participants took a final test with the same 22 questions in randomized order.

RESULTS

Out of the 1350 physiotherapists enrolled, 857 completed the course. The initial responses demonstrated that almost half of the participants considered medical imaging essential before starting physiotherapy treatment, perceived glucocorticoids as recommended for chronic low back pain, and considered ergonomic adjustments crucial for managing the condition. Individuals who completed their education more than 10 years ago showed a minor improvement in evidence-based knowledge compared to those who recently finished their university degree. Following the course, participants displayed improved knowledge, narrowing prior disparities in error percentages across questions.

CONCLUSION

Due to existing gaps in physiotherapists' evidence-based knowledge of LBP, particularly among those who have worked longer time as physiotherapists, e-learning initiatives may be a feasible approach to support continuous training of physiotherapists.

Immediate effect of craniocervical flexion exercise and Mulligan mobilisation in patients with mechanical neck pain - A randomised clinical trial

Background

Mechanical neck pain (MNP) is one of the most prevalent musculoskeletal pathologies in the present time. Physiotherapy management strategies comprising manual therapy and exercise therapy are routinely administered in patients with MNP.

Objective

To compare the immediate effect of craniocervical flexion (CCF) exercise and Mulligan mobilisation on pain, active cervical range of motion (CROM) and CCF test performance in patients with MNP.

Methods

This prospective, randomised, single-blinded study involved 26 patients with MNP (16 females; mean age; 31 . 12 ± 8 . 40 years) randomised to a single session of active CCF exercise (3 sets of 10 repetitions) or Mulligan mobilisation (3 sets of 6-10 repetitions). Pain intensity was measured on a numerical pain rating scale (NPRS), active CROM was measured using CROM device, and CCF test performance with surface electromyography (EMG) from bilateral sternocleidomastoid (SCM) and anterior scalene (AS) muscles recorded pre- and immediately post-intervention by an assessor blinded to the treatment groups. Mann-Whitney U test was used to analyse between groups and Wilcoxon signed rank test was used to analyse within-group significance for pain and CROM, Cochran-Mantel-Haenszel correlation test was used to analyse the CCF test performance on EMG from the bilateral SCM and AS muscles.

Results

Comparison between pre- and post-intervention readings revealed statistically significant within-group (p < 0 . 05 ) and no between-group significant difference for pain, ROM, and CCF test performance, indicating both interventions were equally effective.

Conclusion

Patients with MNP who received active CCF exercise or Mulligan mobilisation exhibited similar reduction in pain intensity and increased CROM and CCF test performance post-intervention. Surprisingly, AS surface EMG amplitudes were increased post-intervention in both groups warranting further exploration of its role in neck pain.

Comparison of transversus abdominis activation characteristics between healthy and chronic low back pain population during upright functional movement

BACKGROUND

Previous literature suggests that transversus abdominis (TrA) activation is diminished in chronic low back pain (cLBP) subjects compared to healthy subjects in less-functional positions. However, few studies have investigated the effects of upright functional movement on TrA activation in cLBP individuals.

OBJECTIVE

This pilot study aimed to compare TrA activation characteristics in healthy and cLBP subjects during the movement of double leg standing (DLS) to single leg standing (SLS) and to a 30∘ single leg quarter squat (QSLS).

METHODS

TrA activation was determined by the percentage change in TrA thickness from DLS to SLS and DLS to QSLS. TrA thickness was measured in 14 healthy and 14 cLBP participants using ultrasound imaging with a probe holder at 20 mm and 30 mm from the fascia conjunction point.

RESULTS

At both measurement points (20 and 30 mm), there were no significant main effects of body sides, lower limb movements and the interactions between them on TrA activations between the healthy and cLBP participants even after covariates were adjusted for (all p> 0.05).

CONCLUSIONS

Results from this study suggest the evaluation of TrA activation during upright functional movements as part of an assessment for cLBP management may not be suggested.

Cost effectiveness of virtual reality game compared to clinic based McKenzie extension therapy for chronic non-specific low back pain

BACKGROUND

Low-back pain (LBP) is a major public health problem globally and its direct and indirect healthcare costs are growing rapidly. Virtual reality involving the use of video games or non-game applications are alternatives to conventional face-to-face physical therapy for LBP. The purpose of this study was to assess the cost-effectiveness of Back Extension-Virtual Reality Game (BE-VRG) compared to Clinic-based McKenzie therapy (CBMT) for chronic non-specific LBP in Nigeria.

METHODS

Patients with chronic non-specific LBP were randomised into either BE-VRG or CBMT group. Patients' level of disability was assessed using Oswestry Disability Index (ODI) at week 4 and week 8. ODI was mapped to SF-6D to generate quality adjusted life years (QALYs) used for cost-effectiveness analysis. Resource use and costs were assessed based on rehabilitation services from a healthcare perspective. Cost-effectiveness analysis which included direct healthcare costs was conducted. Incremental cost per QALY was also calculated.

RESULTS

Forty-six patients (BE-VRG, n = 22; CBMT, n = 24) with the mean (±SD) age of 32.6 ± (11.5) years for BE-VRG and 48.8 ± (10.2) years for CBMT intervention completed in this study. The mean direct health costs per patient were USD100.67 and USD106.3 for BE-VRG and CBMT, respectively. The mean quality adjusted life years at week 4 and week 8 were (BE-VRG, 0.0574 ± (0.002); CBMT, 0.0548 ± (0.002)); and (BE-VRG; 0.116 ± (0.002); CBMT; 0.114 ± (0.004)), respectively. Incremental cost-effectiveness ratio showed that BE-VRG arm was less costly and more effective than CBMT.

CONCLUSION

The findings of this study suggest that BE-VRG was cost saving for chronic non-specific LBP compared to CBMT. This evidence could guide policy makers, payers and clinicians in evaluating BE-VRG as a treatment option for people with chronic non-specific LBP.

Implementation of telerehabilitation in Austrian outpatient physiotherapy – A qualitative study / Implementierung von Telerehabilitation in der ambulanten Physiotherapie in Österreich – Eine qualitative Studie

Background

New technologies, for example, telerehabilitation (TR) tools, can support physiotherapists’ work. Even though studies have demonstrated their potential, TR is not yet fully implemented in Austrian outpatient physiotherapy. As a result of the Coronavirus pandemic and the associated lockdowns, physiotherapists in Austria were confronted with the challenge of offering therapies without physical contact. This study aims to investigate opinions and experiences of physiotherapists in Austria regarding TR and its implementation in different clinical fields.

Methods

A qualitative research design with expert interviews and a focus group discussion were conducted. Data were analysed using content analysis. The categories were formed following a deductive-inductive approach.

Results

The interview partners considered opportunities for using synchronous TR in internal medicine as well as orthopaedics and traumatology, especially in later, exercise-dominated stages. In addition, using TR can be supportive for patient education. In the field of neurology, synchronous TR is viewed with some criticism, especially when used for people with severe neuropsychological disorders. Asynchronous TR is considered useful across all disciplines and could support physical therapy from the first therapy session and throughout the treatment. Important questions regarding liability, billing, or data protection still need to be clarified. Interdisciplinary approaches in TR should also be pursued to improve care.

Conclusion

The use of asynchronous TR in addition to regular physiotherapy is seen as promising in all clinical fields. In general, when implementing TR, the needs and requirements of different fields should be considered. Moreover, various framework conditions still need to be clarified for further implementation of TR.

Impact of Cervical Spine Rehabilitation on Temporomandibular Joint Functioning in Patients with Idiopathic Neck Pain

Objective

The aim of this study was to assess the effectiveness of a 3-week rehabilitation programme focusing only on the cervical region, pain intensity, range of motion in the cervical spine, head posture, and temporomandibular joint (TMJ) functioning in subjects with idiopathic neck pain who did not report TMJ pain.

Design

A parallel group trial with follow-up.

Methods

The study included 60 participants divided into 2 groups: experimental: n = 25, 27-57 years old, experiencing idiopathic neck pain and who underwent a 3-week rehabilitation programme, and the control, n = 35, 27-47 years, who were cervical pain-free. At baseline and after 3 weeks of treatment in the experimental group and with a 3-week time interval in the control group, pain intensity, head posture in the sagittal plane, range of motion in the cervical spine, and TMJ functioning were evaluated.

Results

After 3 weeks of rehabilitation, there was a significant decrease in pain intensity, improved range of motion of the cervical spine and head posture, and improved clinical condition of TMJ in participants with idiopathic neck pain who did not report TMJ pain.

Conclusion

The study suggested that idiopathic neck pain is associated with limited range of motion in the cervical spine, incorrect head posture, and TMJ dysfunction. Our data suggests that therapy focusing only on the cervical region may improve the clinical condition of the TMJ in subjects with idiopathic neck pain who do not report TMJ pain. These observations could be helpful in physiotherapeutic treatment of neck and craniofacial area dysfunctions. This trial is registered with ISRCTN Registry ISRCTN14511735.

Development and Feasibility Testing of an Animated Cartoon-Based Self-Care Application for Low-Back Pain – a Pilot Study

Objectives: Use of animated cartoon for pain management is an emerging area, however, no study have explored it as a digital platform for rehabilitation of low-back pain (LBP). This study was aimed to develop and evaluate the feasibility of an animated cartoon-based self-care (ACBSC) app for LBP, and to examine the correlation between the app rating parameters and patients’ pain. Methods: This two-phase study comprised a development and feasibility testing components. Development of the ACBSC app was based on Mckenzie’s Mechanical Diagnosis and Therapy (MDT) extension protocolplus back hygiene following standard iteration and prototyping process. Twenty-eight consecutive patients with chronic non-specific LBP with 'direction Preference’ for extension based on the MDT screening algorithm participated in the feasibility phase. The participants utilized the cartoon-based app thrice weekly for two weeks. Outcomes were assessed in terms of usability, satisfaction and user’s experience using the system usability scale and mobile application rating scale. Quadruple visual analogue scale was used to assess pain intensity of the participants. Results: On a unified scale of 20, functionality (15.4 ± 2.41) and aesthetics 14 ± 2.00 had highest and least objective quality rating on the app parameters. Total objective and subjective quality rating of the app was 16.9 ± 1.97 and 15.6 ± 2.42 respectively. Total impact and usability score was 24.1 ± 3.39 (out of 30) and 27.8 ± 3.09 (out of 50). Participants reported that back care cartoon app mostly affect mindfulness/meditation/relaxation (42.9%), increases happiness/well-being (46.4%), leads to behavioural change (60.7%) and targets physical health (100%). There was no significant correlation between participants’ pain characteristics and app rating parameters (p>0.05). Conclusion: The animated cartoon-based self-care LBP app has moderate to high usability, functionality, aesthetics and quality rating, and may serve as an effective mobile-app for self-management of long-term LBP.

The influence of cervical spine rehabilitation on bioelectrical activity (sEMG) of cervical and masticatory system muscles

Background

Coexistence of temporomandibular joint discomfort along with cervical spine disorders is quite common, and is associated with many limitations and adverse symptoms for the patient. Both diagnostics and treatment of these ailments are difficult, and in many cases, the effects of therapy are not satisfactory. This study assessed the impact of a 3-week neck-only rehabilitation programme without direct intervention in the craniofacial area on the bioelectric activity of both the cervical spine and muscles in the craniofacial area among patients with idiopathic neck pain who do not report TMJ pain.

Design

A parallel group trial with follow-up; Setting: Rehabilitation Clinic.

Methods

Twenty five patients experiencing idiopathic neck pain underwent the 3-week rehabilitation programme. Thirty five age-matched subjects with no cervical spine and temporomandibular joint (TMJ) dysfunctions were control group. At baseline and after 3 weeks the cervical and craniofacial area muscles’ bioelectrical activity (sEMG) was evaluated.

Results

In the experimental group during cervical flexion, a significant decrease of sEMG amplitude was noted in the right (mean 25.1 μV; 95% CI: 21.5–28.6 vs mean 16.8 μV; 95% CI: 13.8–19.7) and left (mean 25.9 μV; 95% CI: 21.7–30.0 vs mean 17.2 μV; 95% CI: 13.6–20.7) Sternocleidomastoid as well as a significant increase in sEMG amplitude of the right (mean 11.1 μV; 95% CI: 7.9–14.2 vs mean 15.7 μV; 95% CI: 12.1–19.2) and left (mean 15.3 μV; 95% CI: 11.9–18.6 vs mean 20.2 μV; 95% CI: 15.7–24.2) Upper Trapezius muscles. In the experimental group, after therapy right and left Sternocleidomastoid, Temporalis Anterior and Masseter muscles presented lower fatigue levels.

Conclusions

Three weeks of rehabilitation without any therapeutic intervention in temporomandibular joint significantly decreased the bioelectrical activity of the neck and craniofacial muscles while improving the muscle pattern of coactivation in participants with idiopathic neck pain who do not report temporomandibular joint pain. These observations could be helpful in the physiotherapeutic treatment of neck and craniofacial area dysfunctions.

Trial registration

ID ISRCTN14511735—retrospectively registered.

Chiropractic Nimmo Receptor-Tonus Technique and McKenzie Self-Therapy Program in the Management of Adjacent Segment Disease: A Case Report

Objective

The objective of the present study objective was to describe adjacent segment disease (ASD) from a chiropractic management prospective and subsequently to stimulate further research into the chiropractic therapeutic effects on such cases and to contribute to chiropractic literature.

Clinical Features

A 44-year-old woman had a history of lumbar stabilization revision operation by pedicle screw fixation for spondylolisthesis. Her intractable back pain episodes, which were diagnosed as ASD, began shortly after this surgery. At presentation, she was taking pregabalin 75 mg 2 times a day for postoperative neuropathic pain without any pain relief. Clinical testing revealed myofascial tender points reproducing the pain.

Intervention and Outcome

After taking the case history and performing a physical examination, the patient was managed with chiropractic Nimmo receptor-tonus technique in combination with McKenzie exercises. Nimmo was applied by manually pressing on clinically relevant points for 5 to 15 seconds in 11 visits over 3 weeks. The patient by herself did McKenzie exercises 5 to 10 times a day for 10 to 12 repetitions over 2 months. After 3 weeks of therapy, visual analog scale and Oswestry Disability Index scores were improved. Furthermore, because of the amelioration of the patient's symptoms, her neurosurgeon successfully discontinued pregabalin 75 mg 2 times a day without negative consequences to care.

Conclusion

As far as the authors are aware, there is currently no published case of ASD care in chiropractic literature. Our rehabilitative management received a favorable response. It can be hypothesized that it offers a perspective that informs improved patient care.

Measuring upper limb disability for patients with neck pain: Evaluation of the feasibility of the single arm military press (SAMP) test

BACKGROUND

Non-specific neck pain (NSNP) is frequently associated with upper limb disability (ULD). Consequently, evaluation of ULD using an outcome measure is necessary during the management of patients with NSNP. The Single Arm Military Press (SAMP) test is a performance-based ULD measure developed for populations with neck pain. During the SAMP test, patients are asked to repeatedly lift a weight above their head for 30 s. The number of repetitions is counted. Its clinical utility in a patient group is still unknown.

OBJECTIVE

This study investigates the feasibility of the SAMP test from patients and clinicians' perspectives.

METHODS

Seventy female patients with NSNP were randomly allocated into one of three groups. Participants in each group completed the SAMP test using one of three proposed weights (½kg, 1 kg or 1½kg). The feasibility of the SAMP test was established using structured qualitative exit feedback interviews for patients and administrating clinicians.

RESULTS

Participants using ½kg achieved the highest number of repetitions, but a high proportion reported the weight as extremely light, whereas those who tested using the 1½kg achieved the lowest number of repetitions and participants reported the weight as being heavy. Participants tested using 1 kg achieved an average number of repetitions and a high proportion reported the weight as acceptably heavy. Clinicians and patients reported that the SAMP test was efficient and convenient.

CONCLUSION

The 1 kg SAMP test is feasible for use in female patients with NSNP. The measurement properties of the SAMP test should be determined in a patient group.

Efficacy of a proprioceptive exercise program in patients with nonspecific neck pain: a randomized controlled trial

BACKGROUND

Nonspecific neck pain is associated with chronic pain, disability, reduced cervical mobility, postural control disorders and impaired proprioceptive control.

AIM

The aim of this study was to compare the effectiveness of two therapeutic exercise programs (i.e. cervical proprioception and cervical mobility) in reducing pain and disability in individuals with nonspecific neck pain. We further aimed to compare the effectiveness of the two treatments in improving pressure pain threshold, cervical range of motion and head repositioning accuracy.

DESIGN

This study was designed as a randomized controlled trial.

SETTING

This study took place in a private rehabilitation clinic.

POPULATION

Forty-two participants diagnosed with nonspecific neck pain, aged 18-65 years, were randomized to a cervical mobility group (N.=22) or a proprioception group (N.=20).

METHODS

The cervical mobility group combined a passive treatment and active mobility exercises, whereas the Proprioception group combined a passive treatment and proprioceptive exercises. Pain intensity, disability, pressure pain threshold, range of motion, and head repositioning accuracy were assessed at baseline and after 10 sessions.

RESULTS

Pain intensity and disability significantly improved for both interventions (p<0.01), but such improvement was greater for pain intensity in the proprioception group than in the cervical mobility group (P<0.01). Pressure pain threshold, range of motion and head repositioning accuracy improved only in the proprioception group (P<0.01).

CONCLUSIONS

A program based on cervical proprioception exercises demonstrated to improve pain, disability, pressure pain threshold, range of motion and head repositioning accuracy in patients with nonspecific neck pain. However, a program based on cervical mobility exercises only showed to improve pain intensity and disability, while such improvement was not clinically relevant.

CLINICAL REHABILITATION IMPACT

The proprioceptive exercise program may be considered as the treatment of choice in patients with nonspecific neck pain.

Development, validation and evaluation of a novel self-instructional module in patients with chronic non-specific low back pain

Background

Low back pain (LBP) is ranked highest in terms of disability-adjusted life-years lived. Patient education and self-management have shown to play a crucial role in the overall pain management. However, the literature on the same with respect to Indian context is still lacking. The study was aimed to develop, validate and assess the acceptability and effectiveness of self-instructional educational module among Indian chronic LBP (CLBP) patients.

Methods

A prospective single-arm open-label study was conducted in a pain clinic of a tertiary care public hospital in North India with 'Backcare booklet-self-instructional module (SIM)' as an intervention in patients with CLBP. SIM was developed with the intent to provide up-to-date evidence-based information in an easy understanding way to patients with CLBP. 132 patients were administered SIM with a single session of verbal explanation. Pain intensity (numeric rating scale [NRS]), disability, fear-avoidance belief Questionnaire (FABQ), quality of life (EQ5D) and knowledge level were assessed at baseline and after 3 months of intervention. Student's paired t-test and Chi-square test were used. Data were analysed using SPSS version 15.0.

Results

120 patients successfully completed the 3 months' follow-up. Significant reductions were observed in pain intensity (76[12] vs 55 [15, P < 0.01); disability (51[14] vs 43 [10], P < 0.01); FABQ (46[12] vs 41 [10], P < 0.01); EQ5D (0.35 [0.27] vs 0.18 [0.26], P < 0.01).

Conclusion

Backcare booklet as an intervention, along with usual pharmacological care is a cost-effective educational medium to promote self-management of CLBP in the clinical outpatient settings.

A randomized clinical trial comparing non-thrust manipulation with segmental and distal dry needling on pain, disability, and rate of recovery for patients with non-specific low back pain

Objective: The purpose of this study was to examine the within and between-group effects of segmental and distal dry needling (DN) without needle manipulation to a semi-standardized non-thrust manipulation (NTM) targeting the symptomatic spinal level for patients with non-specific low back pain (NSLBP). Methods: Sixty-five patients with NSLBP were randomized to receive either DN (n = 30) or NTM (n = 35) for six sessions over 3 weeks. Outcomes collected included the oswestry disability index (ODI), patient specific functional scale (PSFS), numeric pain rating scale (NPRS), and pain pressure thresholds (PPT). At discharge, patients perceived recovery was assessed. Results: A two-way mixed model ANOVA demonstrated that there was no group*time interaction for PSFS (p = 0.26), ODI (p = 0.57), NPRS (p = 0.69), and PPT (p = 0.51). There was significant within group effects for PSFS (3.1 [2.4, 3.8], p = 0.018), ODI (14.5% [10.0%, 19.0%], p = 0.015), NPRS (2.2 [1.5, 2.8], p = 0.009), but not for PPT (3.3 [0.5, 6.0], p = 0.20). Discussion: The between-group effects were neither clinically nor statistically significant. The within group effects were both significant and exceeded the reported minimum clinically important differences for the outcomes tools except the PPT. DN and NTM produced comparable outcomes in this sample of patients with NSLBP. Level of evidence: 1b.

Patients' perspective of the effectiveness and acceptability of pharmacological and non-pharmacological treatments of fibromyalgia

Background and aims Fibromyalgia is a complex condition characterised by widespread pain, sleep disturbance, fatigue and cognitive impairment, with a global mean prevalence estimated at 2.7%. There are inconsistencies in guidelines on the treatment of fibromyalgia leading to dissatisfaction from patients and healthcare professionals. This study investigated patient-reported outcomes of pharmacological and non-pharmacological treatment usage and effectiveness with an assessment of acceptability. Methods Nine hundred and forty-one participants completed a self-administered anonymous questionnaire giving quantitative data of demographics, treatment usage and treatment outcomes. Participant-reported effectiveness and side effects were compared in the following treatment classes: analgesics, antidepressants, gabapentinoids, gastrointestinal treatments, activity interventions, dietary-based treatments, and psychological, physical and alternative therapies. Participants also reported whether they knew about or had tried different treatments. Results The results from the online survey indicated that the range of mean effectiveness ratings were similar for pharmacological and non-pharmacological treatments, whereas non-pharmacological treatments had lower side effects ratings and higher acceptability relative to pharmacological treatments. Participants were not aware of some treatment options. Conclusions The results show lower side effects ratings and higher acceptability for non-pharmacological treatments compared to pharmacological treatments despite similar effectiveness ratings. Implications This article presents results from a large online survey on fibromyalgia patient perspectives of pharmacological and non-pharmacological treatments. Results will inform healthcare professionals and patients about optimal treatments based on ratings of effectiveness, side effects and acceptability that are tailored to patient symptom profiles. Some participants were unaware of treatment options highlighting the importance of patient education allowing collaboration between patients and healthcare professionals to find optimal treatments.

Effectiveness of physical therapy and exercise on pain and functional status in patients with chronic low back pain: a randomized-controlled trial

OBJECTIVES

This study aims to investigate the effect of physical therapy modalities on pain and functional status in patients with non-specific low back pain.

PATIENTS AND METHODS

Between February 2011 and August 2013, a total of 104 patients (38 males, 66 females; mean age 49.3±12.5 years; range 34 to 62 years) with non-specific chronic low back pain for more than 12 weeks without any neurological deficit were included in this randomized-controlled study. The patients were divided into two groups: physical therapy group (n=52) and control group (n=52). Both groups were given exercise and medical treatment; physiotherapy modalities were also applied in the physical therapy group. The patients were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Istanbul Low Back Pain Disability Index (ILBP) before treatment and at two weeks, three months, and one year after treatment.

RESULTS

A total of 100 patients completed one-year follow-up. In both groups, the VAS, ODI, and ILBP significantly improved after treatment (p<0.01), compared to before treatment values. There were statistically significant differences in the VAS, ODI, and ILBP scores at three months and one year after treatment between the physical therapy group and control group (p<0.05).

CONCLUSION

Multidisciplinary approaches including physical therapy should be implemented to provide long-term improvement in pain and functional status in the treatment of non-specific chronic low back pain.

Understanding and Treating Pain Syndromes in Parkinson's Disease

Pain affects many people with Parkinson's disease (PD) and diminishes their quality of life. Different types of pain have been described, but their related pathophysiological mechanisms remain unclear. The aim of this chapter is to provide movement disorders specialists an update about the pathophysiology of pain and a practical guide for the management of pain syndromes in clinical practice. This chapter reviews current knowledge on the pathophysiological mechanisms of sensory changes and pain in PD, as well as assessment and treatment procedures to manage these symptoms. In summary, changes in peripheral and central pain processing have been demonstrated in PD patients. A decrease in pain threshold and tolerance to several stimuli, a reduced nociceptive withdrawal reflex, a reduced pain threshold, and abnormal pain-induced activation in cortical pain-related areas have been reported. There is no direct association between improvement of motor symptoms and sensory/pain changes, suggesting that motor and nonmotor symptoms do not inevitably share the same mechanisms. Special care in pain assessment in PD is warranted by the specific pathophysiological aspects and the complexity of motor and nonmotor symptoms associated with pain symptoms. Rehabilitation may represent a valid option to manage pain syndromes in PD. However, further research in this field is needed. An integrated approach to pain involving a multidisciplinary team of medical specialists and rehabilitation experts should allow a comprehensive approach to pain in PD.

Increasing Recreational Physical Activity in Patients With Chronic Low Back Pain: A Pragmatic Controlled Clinical Trial

Study Design Prospective, pragmatic, nonrandomized controlled clinical trial. Background Clinical guidelines recommend physical activity for the treatment of chronic low back pain. But engaging patients in physical activity has proven difficult. Known obstacles to physical activity include low self-efficacy and fear avoidance. Objectives This study tested the effectiveness of an enhanced transtheoretical model intervention (ETMI) aimed at increasing recreational physical activity in patients with chronic low back pain, in comparison to usual physical therapy. Methods Patients (n = 220) referred to physical therapy for chronic low back pain were allocated to ETMI or to a control group. The ETMI was delivered by physical therapists and based on behavior-change principles, combined with increased reassurance, therapeutic alliance, and exposure to reduce fear avoidance. The primary outcome was back pain-related disability (Roland-Morris Disability Questionnaire). Secondary outcomes included pain intensity, mental and physical health, and levels of physical activity. Results Intention-to-treat analysis in 189 patients at 12 months indicated that patients in the ETMI group had significantly lower disability compared to usual physical therapy. The difference in mean change from baseline between the interventions was 2.7 points (95% confidence interval: 0.9, 4.5) on the Roland-Morris Disability Questionnaire. At 12 months, worst pain, physical activity, and physical health were all significantly better in patients receiving ETMI. The average number of sessions was 3.5 for the ETMI group and 5.1 for controls. Conclusion Targeting obstacles to physical activity with an intervention that includes components to address self-efficacy and fear avoidance appears to be more effective than usual physical therapy care in reducing long-term disability. Further research is needed to explore the mechanisms that impact outcomes in this intervention package. Level of Evidence Therapy, level 2b. Registered June 7, 2012 at ClinicalTrials.gov (NCT01631344). J Orthop Sports Phys Ther 2017;47(2):57-66. doi:10.2519/jospt.2017.7057.

Access to publicly funded outpatient physiotherapy services in Quebec: waiting lists and management strategies

PURPOSE

Problems with access to outpatient physiotherapy services have been reported in publicly funded healthcare systems worldwide. A few studies have reported management strategies aimed at reducing extensive waiting lists, but their association with waiting times is not fully understood. The purpose of this study was to document access to public outpatient physiotherapy services for persons with musculoskeletal disorders in hospitals and explore organizational factors associated with waiting time.

METHODS

We surveyed outpatient physiotherapy services in publicly funded hospitals in the province of Quebec (Canada).

RESULTS

A total of 97 sites responded (99%) to the survey. The median waiting time was more than six months for 41% of outpatient physiotherapy services. The waiting time management strategies most frequently used were attendance and cancelation policies (99.0%) and referral prioritization (95.9%). Based on multivariate analyses, the use of a prioritization process with an initial evaluation and intervention was associated with shorter waiting times (p = 0.008).

CONCLUSIONS

Our findings provide evidence that a large number of persons wait a long time for publicly funded physiotherapy services in Quebec. Based on our results, implementation of a prioritization process with an initial evaluation and intervention could help improve timely access to outpatient physiotherapy services. Implications for Rehabilitation Access to publicly funded outpatient physiotherapy services is limited by long waiting times in a great proportion of Quebec's hospitals. The use of a specific prioritization process that combines an evaluation and an intervention could possibly help improve timely access to services. Policy-makers, managers, and other stakeholders should work together to address the issue of limited access to publicly funded outpatient physiotherapy services.

Effects of Cervical Extension on Deformation of Intervertebral Disk and Migration of Nucleus Pulposus

BACKGROUND

We theorized that active cervical extension should influence the position of the nucleus pulposus (NP) within the intervertebral disk (IVD) in the sagittal plane. Although several studies on the lumbar IVD have been conducted, there are no quantitative data for in vivo positional changes of the NP in the cervical IVD.

OBJECTIVE

To evaluate the influence and mechanism of cervical extension on the deformation and migration of IVD and NP in the sagittal plane and understand underlying mechanisms of the extension maneuver.

DESIGN

Asymptomatic subjects underwent magnetic resonance imaging while supine with their cervical spines in neutral and extended positions.

SETTING

Academic medical center.

PARTICIPANTS

Ten young, healthy male participants (age range 19-30 years; mean 22.4 ± 1.64 years).

METHODS

T2-weighted sagittal images from C3-C4 to C6-C7 of subjects in both neutral and extension positions were analyzed.

MAIN OUTCOME MEASUREMENTS

Deformation of IVD and positional change of NP were quantified and compared between neutral and extension positions. Intersegmental angles between vertebrae, horizontal positions of anterior and posterior IVD and NP margins, IVD outer and inner heights, and sagittal morphology of NP were quantified and compared between the neutral and extension positions. Correlations between the measured parameters and segmental extension angle were also investigated.

RESULTS

Anterior and posterior IVD margins moved posteriorly with respect to the vertebral body in extension. Both NP margins remained unchanged relative to the vertebral body but moved anteriorly with respect to the IVD. IVD outer and inner heights in the anterior region increased in extension, and morphological changes of the NP were less noticeable when compared with its relative migration within the IVD. Most of the intradiskal changes were linearly correlated with the segmental extension angle.

CONCLUSIONS

Cervical extension induces anterior migration of the NP away from the posterior disk margin and may have a clinical effect on diskogenic neck pain resulting from internal disk disruption.

LEVEL OF EVIDENCE

Not applicable.

The influence of home exercise programs for patients with non-specific or specific neck pain: a systematic review of the literature

STUDY DESIGN

Systematic review of randomized controlled trials (RCT).

OBJECTIVES

To examine the effects of a therapeutic home exercise program (HEP) for patients with neck pain (associated with whiplash, non-specific, or specific neck pain, with or without radiculopathy, or cervicogenic headache) on pain, function, and disability. Our secondary aim was to describe the design, dosage, and adherence of the prescribed HEPs.

BACKGROUND

Neck pain is a leading cause of disability that affects 22-70% of the population. Different techniques have been found effective for the treatment of neck pain. However, there is conflicting evidence to support the role of a therapeutic HEP to reduce pain, disability, and improve function and quality of life (QOL).

METHODS

A systematic review in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement for reporting systematic reviews. The full-text review utilized the Maastricht-Amsterdam assessment tool to assess quality among RCTs.

RESULTS

A total of 1927 subjects included within seven full-text articles met our specific search strategy. It was found that HEPs with a focus on strength and endurance-training exercises, as well as self- mobilization, have a positive effect when used in combination with other conservative treatments or alone.

CONCLUSIONS

Home exercise programs that utilize either self-mobilizations within an augmented HEP to address specific spinal levels, or strengthening, and/or endurance exercise are effective at reducing neck pain, function, and disability and improving QOL. The benefit of HEPs in combination with other conservative interventions yields some benefit with a range of effect sizes.

[Chronic low back pain : Comparison of mobilization and core stability exercises]

BACKGROUND

For the treatment of chronic low back pain (cLBP), both core stability and mobilization exercises were introduced. The aim of this prospective randomized clinical pilot study was to compare the efficacy of mobilization and core stability exercises with regard to objective and subjective outcome measures in patients with cLBP.

METHOD

After a per-protocol analysis, the data of 27 patients with cLBP, who were randomly allocated to one of the two groups, were analyzed. The intervention group (GM) performed mobilization exercises using the BALLance-Methode®, the control group (GS) carried out core stability exercises for 4 weeks, and continued the exercises for an additional 4 weeks at home. Flexibility, strength endurance of the core stabilizing muscles, pain-induced disability, and pain avoidance behavior were the objective and subjective outcomes that were measured before, 4 weeks after, and 8 weeks after the onset of the intervention. The significance of differences within and between groups was analyzed.

RESULTS

During the observation period, only in the GS patients could maintain the prone-plank position and the side-plank position improvements over time (p < 0.001), with significant differences compared with the GM (p < 0.05). Within both groups significant improvements in the subjective outcome measures were found (p < 0.05). Therefore, no significant differences existed between the groups.

CONCLUSION

With regard to their daily complaints, patients with cLBP can be treated using standardized mobilization exercises in addition to core stability exercises.

Exercises for mechanical neck disorders

BACKGROUND

Neck pain is common, disabling and costly. Exercise is one treatment approach.

OBJECTIVES

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

MAIN RESULTS

Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

AUTHORS' CONCLUSIONS

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

A holistic approach to chronic pain management that involves all stakeholders: change is needed

Chronic pain affects a large proportion of the population, imposing significant individual distress and a considerable burden on society, yet treatment is not always instituted and/or adequate. Comprehensive multidisciplinary management based on the biopsychosocial model of pain has been shown to be clinically effective and cost-efficient, but is not widely available. A literature review of stakeholder groups revealed many reasons for this, including: i) many patients believe healthcare professionals lack relevant knowledge, and consultations are rushed, ii) general practitioners consider that pain management has a low priority and is under-resourced, iii) pain specialists cite non-adherence to evidence-based treatment, sub-optimal prescribing, and chronic pain not being regarded as a disease in its own right, iv) nurses', pharmacists' and physiotherapists' skills are not fully utilized, and v) psychological therapy is employed infrequently and often too late. Many of the issues relating to physicians could be addressed by improving medical training, both at undergraduate and postgraduate levels - for example, by making pain medicine a compulsory core subject of the undergraduate medical curriculum. This would improve physician/patient communication, increase the use of standardized pain assessment tools, and allow more patients to participate in treatment decisions. Patient care would also benefit from improved training for other multidisciplinary team members; for example, nurses could provide counseling and follow-up support, psychologists offer coping skills training, and physiotherapists have a greater role in rehabilitation. Equally important measures include the widespread adoption of a patient-centered approach, chronic pain being recognized as a disease in its own right, and the development of universal guidelines for managing chronic non-cancer pain. Perhaps the greatest barrier to improvement is lack of political will at both national and international level. Some powerful initiatives and collaborations are currently lobbying policy-making bodies to raise standards and reduce unnecessary pain - it is vital they continue.

Translation of the fear avoidance beliefs questionnaire into Hausa language

BACKGROUND

Self-report measures of fear-avoidance beliefs are widely used in clinical practice and research. To date there is no Hausa version of the Fear Avoidance Beliefs Questionnaire (FABQ). This is important as the Hausa language is a widely spoken language in West Africa.

OBJECTIVES

The purpose of this study was to translate and validate the Hausa version of the FABQ in patients with non-specific neck pain.

METHODS

Two independent bilingual Hausa translators translated the English version of the FABQ into Hausa which was thereafter back translated by one independent bilingual translator. A professional expert panel revised the translations to produce a consensus version. The psychometric testing of the final translated instrument was investigated by surveying 54 Hausa speaking patients with chronic non-specific neck pain. Cross-sectional construct validity was evaluated by comparing Hausa Fear Avoidance Beliefs Questionnaire (FABQ-H) with the English version of the FABQ. Internal consistency of the FABQ-H was examined by Cronbach alpha by comparing the scores between the FABQ-H and its subscales. Test-retest reliability was evaluated by administering the Hausa version twice.

RESULTS

The translated Hausa version of FABQ proved to be acceptable. The FABQ-H showed strong correlations (r=0.94, p=0.000) with the original English version. There was also high internal consistency between the FABQ-H and its subscales (physical activity component-alpha=0.88, p=0.000 and work component- alpha=0.94, p= 0.000). The FABQ-H also showed a high test-retest reliability (intra-class correlation coefficient =0.98).

CONCLUSION

The FABQ-H demonstrated excellent psychometric properties similar to other existing versions. The FABQ-H is recommended for clinical practice.

Australian physiotherapists and their engagement with people with chronic pain: do their emotional responses affect practice?

This study explores the experiences of Australian physiotherapists who see people with chronic pain as part of their daily practice. It has been established in the literature that Australian physiotherapists do not manage people with chronic pain well; however, the reasons for this are not well understood. This study aimed to explore this phenomenon through a qualitative approach that generated data about the perceptions of physiotherapists in regard to caring for people with chronic pain. Fourteen physiotherapists were interviewed using a semi-structured interview approach. The results indicate that the therapists experience emotional responses to people with chronic pain, which lead to difficulties in being able to successfully provide effective care. These findings also provide the beginnings of a framework that may support physiotherapists in engaging more successfully with people with chronic pain.

Cervical Spondylotic Myelopathy presenting as mechanical neck pain: a case report

Cervical Spondylotic Myelopathy (CSM) is the most common type of myelopathy in adults over 55 years of age. In the early stages symptoms may include local neck pain and stiffness that might mimic the presentation of non-specific mechanical neck pain (NSMNP). The patient was a 79 year old male, who complained of eight weeks of neck pain. He had been referred for physiotherapy by his family physician with a diagnosis of NSMNP. Initial presentation was consistent with the referral, but further assessment by the physiotherapist revealed findings suggestive of CSM. He was referred for an urgent cervical MRI scan, which revealed myelomalacic changes at C3/4 due to spondylotic changes. The patient was unsuitable for manual therapy intervention and was referred to a spinal orthopaedic surgeon who performed a posterior decompression and stabilisation at C3-C5, 2 months after the initial presentation. This case report highlights the importance of considering CSM in adults over 55 years of age presenting with NSMNP, particularly as the prevalence of both increases with age. It demonstrates the need for health professionals to carry out detailed examination where CSM may be a potential differential diagnosis. Outcomes are less favourable for patients over the age of 70, therefore an urgent surgical opinion was required for this patient. Deterioration of symptoms whilst he awaited surgery demonstrates how missed diagnosis may lead to possible long term spinal cord damage, with potential medico-legal concerns for the therapist.

Initial management decisions after a new consultation for low back pain: implications of the usage of physical therapy for subsequent health care costs and utilization

OBJECTIVES

To describe the utilization of physical therapy following a new primary care consultation for low back pain (LBP) and to examine the relations between physical therapy utilization and other variables with health care utilization and costs in the year after consultation.

DESIGN

Retrospective cohort obtained from electronic medical records and insurance claims data.

SETTING

Single health care delivery system.

PARTICIPANTS

Individuals (N=2184) older than 18 years with a new consultation for LBP from 2004 to 2008.

INTERVENTIONS

Patients were categorized as receiving initial physical therapy management if care occurred within 14 days after consultation.

MAIN OUTCOME MEASURES

Total health care costs for all LBP-related care received in the year after consultation were calculated from claims data. Predictors of utilization of emergency care, advanced imaging, epidural injections, specialist visits, and surgery were identified using multivariate logistic regression. The generalized linear model was used to compare LBP-related costs based on physical therapy utilization and identify other cost determinants.

RESULTS

Initial physical therapy was received by 286 of the 2184 patients (13.1%), and was not a determinant of LBP-related health care costs or utilization of specific services in the year after consultation. Older age, mental health, or neck pain comorbidity and initial management with opioids were determinants of cost and several utilization outcomes.

CONCLUSIONS

Initial physical therapy management was not associated with increased health care costs or utilization of specific services following a new primary care LBP consultation. Additional research is needed to examine the cost consequences of initial management decisions made following a new consultation for LBP.

Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs.

SUMMARY OF BACKGROUND DATA

Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed.

METHODS

Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined.

RESULTS

Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care.

CONCLUSION

Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear.

OBJECTIVES

To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

Computerized searches were conducted up to February 2012.

SELECTION CRITERIA

We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses.

MAIN RESULTS

Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.

Multi-factorial causative model for back pain management; relating causative factors and mechanisms to injury presentations and designing time- and cost effective treatment thereof

Back pain resolution has not statistically improved over many years with some literature suggesting chronic back pain to be increasing. From a search of literature on causes, events, mechanisms, factors and treatment for back pain, a model is developed that relates causes of back injury to factors that result in pain through two primary mechanisms; muscle fatigue and muscle/tendon/connective tissue strain or sprain with other main mechanisms being diminished reactivity and strength, changes in tendon/tissue mechanical properties and fear of back pain recurrence/fear of movement following a back pain episode. The model highlights the fact that back pain/injury is multi-factorial with numerous circular relationships. Therefore treatment should also be multi-factorial; a combination of physical and psychological therapy with attention to mechanisms at work or in daily living that exacerbate the injury and delay recovery thereof. Exercise is one method that can reduce muscle imbalance, improve resilience to muscle fatigue, and address reactivity and strength. More importantly, eccentric exercise can rectify musculotendinous or connective tissue injury which plays a role in prolonging the back injury cycle. Posture is identified as a causative factor for back pain with the time exposure for posture representing the largest portion of daily activities. From literature and from clinical observation, treatment methods can be improved and incorporated into integrated multi-modal programs. An integrated exercise program that commences with motor control exercise and progresses into functional movement is suggested. Furthermore a modification of the McKenzie extension movement may benefit back injury rehabilitation for a majority of lower back pain patients. Otherwise the sit-to-stand movement is a regular and frequent exacerbating mechanism of back pain and likely continuously tears connective tissue during the movement thus prolonging the cycle of back pain and can be addressed instantly with a modification in sit-to-stand technique.

Chronic neck pain and treatment of cognitive and behavioural factors: results of a randomised controlled clinical trial

PURPOSE

Although there is growing evidence in favour of the bio-psychosocial approach to the treatment of persistent neck pain, it is questioned whether treating psychological factors can improve patient perceptions of disability, pain and quality of life. This randomised, controlled study with 12 months' follow-up was conducted to evaluate the efficacy of adding cognitive-behavioural principles to exercises for chronic neck pain.

METHODS

Eighty patients were randomly assigned to the usual neck exercises plus cognitive-behavioural treatment (PTcb group, 40 subjects) or to treatment based on neck exercises alone (PT group, 40 subjects). Before treatment (T1), at the end of treatment (T2) and 12 months later (T3), all of the patients completed a booklet including the Neck Pain and Disability Scale, a numerical rating scale, and the Short-Form Health Survey Questionnaire (SF-36).

RESULTS

The present trial failed to demonstrate its primary end point: the pre- and post-treatment difference in total NPDS scores was not statistically different between groups. Disability improved similarly in both groups over time, remaining stable until T3 in the PTcb group and slightly increasing at the same time in the PT group. Pain trends were comparable, with both groups showing an improvement between T1 and T2, and a slight worsening between T2 and T3. There were significant increases in all of the SF-36 domains except for health in general, and vitality in both groups by the end of treatment. SF-36 showed a between-group difference only for the physical activity domain (10.4; 95% CI 2.4-18.5).

CONCLUSION

Disability, pain and quality of life improved at the end of treatment in both groups, without differences between them.