Exploration of physicians' recommendations for activities in chronic low back pain

Evaluation of the psychometric properties of the health care providers' pain and impairment relationship scale (HC-PAIRS) in health professionals and university students from Chile and Colombia

Background

Chronic back pain is a frequent and disabling health problem. There is evidence that ignorance and erroneous beliefs about chronic low back pain among health professionals interfere in the treatment of people who suffer from it. The Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) has been one of the most used scale to assess these misbeliefs, but no studies have been reported in Latin America. Method: We studied the factorial structure of the HC-PAIRS in health personnel and health sciences university students in two Latin American countries: Colombia (n = 930) and Chile (n = 190). Spain's data was taken of the original study of the Spanish version of the HC-PAIRS (171 Physiotherapy students). Additionally, the measurement invariance of this scale among Chile, Colombia and Spain was evaluated by calculating three nested models: configural, metric and scalar. We used a Confirmatory Factor Analysis (CFA) in both Latin American samples, with Maximum Likelihood Robust (MLR) estimation to estimate the parameters. For the final model in each sample, reliability was assessed with the Composite Reliability (CR) index, and to obtain the proportion of variance explained by the scale the Average Variance Extracted (AVE) was calculated.

Results

The one-factor solution shows an acceptable fit in both countries after deleting items 1, 6, and 14. For the resulting scale, the CR value is adequate, but the AVE is low. There is scalar invariance between Chile and Colombia, but not between these two countries and Spain.

Conclusions

HC-PAIRS is useful for detecting misconceptions about the relationship between chronic low back pain that would cause health personnel to give wrong recommendations to patients. However, it has psychometric weaknesses, and it is advisable to obtain other evidence of validity.

The influence of low back pain-related attitudes and beliefs on the clinical decision making of physical therapists

BACKGROUND

The LBP-related attitudes and beliefs of clinicians may impact the experience of patients by influencing clinician decision-making and by shaping the attitudes, beliefs, and actions of patients. The purpose of this study was to identify the specific LBP-related attitudes and beliefs of US-based physical therapists and determine if those beliefs correlate with clinical decision-making.

METHODS

An electronic survey was sent to US-based physical therapists. Attitudes and beliefs were measured using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain and Impairment Relationship Scale for Physiotherapists (PABS-PT). The survey also included 2 patient vignettes that collected information about clinical decision-making.

RESULTS

Complete survey responses were recorded from 420 physical therapists. Eleven of the 27 attitude and beliefs questions were answered in a more biomedically oriented way by at least 20% of respondents. Physical therapist low back pain-related attitudes and beliefs were associated with activity and management strategies for both vignettes in the expected direction. Higher scores on HC-PAIRS and PABS-BM were associated with more restrictive work and activity recommendations, lower-intensity exercise choices, biomechanical rationale for manual therapy and motor control exercises, pathoanatomical-focused education, and use of modalities.

CONCLUSION

Some physical therapists hold biomedically oriented beliefs about the connection between pain and physical activity. Clinician beliefs were associated with activity and work recommendations, and treatment choices. Physical therapists with more biomedically oriented beliefs were more likely to limit physical activity and work, and less likely to incorporate psychologically informed interventions.

Assessment of back pain behaviors, attitudes, and beliefs of chiropractic research conference attendees after a biopsychosocial educational workshop

OBJECTIVE

The purpose of this study was to assess the behaviors, attitudes, and beliefs of attendees of a chiropractic research conference (which included chiropractic students, clinicians, researchers, and educators) toward chronic low back pain (CLBP) before and after a biopsychosocial (BPS)-based CLBP educational workshop.

METHODS

This single-arm intervention study used the Health Care Providers' Pain and Relationship Scale (HC-PAIRS) and CLBP-related clinic vignettes to assess behaviors, attitudes, and beliefs toward CLBP before and after a single 90-minute educational workshop. The HC-PAIRS is a self-reporting questionnaire that consists of 15 items rated on a 7-point rating scale, with a higher score suggesting a belief that pain is linked to movement and that recommendations should be given to avoid physical activities.

RESULTS

The pre-education intervention HC-PAIRS and vignettes were completed by 40 of 56 attendees. A total of 18 participants completed the posteducation intervention HC-PAIRS and CLBP-related clinical vignettes. Most of participants identified as full-time clinicians, employees of the United States Department of Veterans Affairs, and musculoskeletal/neuromusculoskeletal providers. The pre-education intervention HC-PAIRS mean score was 44.8 (SD 9.22), and the postscore was 39.5 (SD 6.49).

CONCLUSION

Findings suggest an immediate change in HC-PAIRS scores following a BPS-focused CLBP education intervention for a chiropractic audience. However, due to limitations related to sample size and target population, findings should be interpreted cautiously.

Attitudes, beliefs, and recommendations for persistent low back pain patients: cross-sectional surveys of students and faculty at a chiropractic college

BACKGROUND

While the use of chiropractic care for persistent low back pain (PLBP) is prevalent, chiropractors' attitudes and beliefs related to PLBP patients are not fully understood. The purpose of this study was to assess the attitudes, beliefs and activity/work recommendations of students and faculty at a chiropractic college regarding PLBP patients.

METHODS

The Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS) and clinical vignettes were requested to be completed by chiropractic students and faculty at Parker University in April 2018. Higher HC-PAIRS scores indicate stronger beliefs that PLBP justifies disability and limitation of activities. Activity and work recommendations from clinical vignettes were rated as "adequate", "neutral", or "inadequate", as defined in previous literature. Descriptive statistics, independent t-tests, and logistic regression were used to analyze results.

RESULTS

Student and faculty response rates were 63.6% and 25.9%, respectively. Faculty mean HC-PAIRS scores (3.66 [SD:0.88]) were significantly lower than students' (4.41 [SD:0.71]). The percentage of faculty providing "adequate" activity (62.1%) and work (41.0%) recommendations was significantly greater than the percentage of students (activity: 33.9%, work: 21.2%) (p < 0.05). Higher HC-PAIRS scores in students were associated with decreased odds of providing "adequate" activity and work recommendations.

CONCLUSIONS

Student and faculty attitudes and beliefs, and students' activity/work recommendations were found to be dissimilar to those from similar studies and less congruent with CPG recommendations. Lower HC-PAIRS scores increased the odds of students providing "adequate" activity and work recommendations to patients with PLBP. Results from this study may help guide future research and training opportunities.

Exploring the complexity of commonly held attitudes and beliefs of low back pain-a network analysis

Objectives

The current study used a network analysis approach to explore the complexity of attitudes and beliefs held in people with and without low back pain (LBP). The study aimed to (1) quantify the adjusted associations between individual items of the Back Pain Attitudes Questionnaire (Back-PAQ), and (2) identify the items with the strongest connectivity within the network.

Methods

This is a secondary data analysis of a previously published survey using the Back-PAQ (n = 602). A nonparametric Spearman's rank correlation matrix was used as input to the network analysis. We estimated an unregularised graphical Gaussian model (GGM). Edges were added or removed in a stepwise manner until the extended Bayesian information criterion (EBIC) did not improve. We assessed three measures of centrality measures of betweenness, closeness, and strength.

Results

The two pairwise associations with the greatest magnitude of correlation were between Q30-Q31 [0.54 (95% CI 0.44 to 0.60)] and Q15-Q16 [0.52 (95% CI 0.43 to 0.61)]. These two relationships related to the association between items exploring the influence of attentional focus and expectations (Q30-Q31), and feelings and stress (Q15-Q16). The three items with the greatest average centrality values, were Q22, Q25, and Q10. These items reflect beliefs about damaging the back, exercise, and activity avoidance, respectively.

Conclusion

Beliefs about back damage, exercise, and activity avoidance are factors most connected to all other beliefs within the network. These three factors may represent candidate targets that clinicians can focus their counseling efforts on to manage unhelpful attitudes and beliefs in people experiencing LBP.

Comparing physical therapy students' attitudes and beliefs regarding chronic low back pain and knee osteoarthritis: an international multi-institutional comparison between 2013 and 2020 academic years

BACKGROUND

In 2013, physical therapy students demonstrated low guideline-adherent recommendations regarding chronic low back pain (CLBP) for spinal pathology, activity, and work.

OBJECTIVES

To assess the differences in physical therapy students' attitudes, beliefs, and adherence to guideline recommendations regarding CLBP and knee osteoarthritis between 2013 and 2020.

METHODS

In 2013 and 2020, second and fourth-year physical therapy students were recruited from 6 Belgian and 2 Dutch institutions. Attitudes and beliefs regarding CLBP and knee OA were evaluated using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), and a questionnaire regarding therapeutic exercise and knee osteoarthritis. A clinical vignette was used to measure guideline-adherent recommendations regarding spinal pathology, activity, and work.

RESULTS

In 2013, 927 second-year and 695 fourth-year students; in 2020, 695 second-year and 489 fourth-year students; were recruited to participate in the study. Compared to 2013, students had less biomedical and stronger biopsychosocial attitudes and beliefs regarding CLBP, more guideline-adherent recommendations for activity, and more biopsychosocial beliefs regarding the benefits of exercise for patients with knee osteoarthritis in both the second and fourth year. Only fourth-year students in 2020 scored significantly better on HC-PAIRS and guideline-adherent recommendation relating to spinal pathology. No differences were found regarding work recommendations.

CONCLUSIONS

Between 2013 and 2020, physical therapy students made a positive shift towards a more biopsychosocial approach to CLBP and knee osteoarthritis management. Guideline-adherent recommendations for CLBP concerning activity improved, however, concerning work and spinal pathology, it remained low.

Management of acute non-specific low back pain in the emergency department: do emergency physicians follow the guidelines? Results of a cross-sectional survey

OBJECTIVES

Clinical guidelines for acute non-specific low back pain (LBP) recommend avoiding imaging studies or invasive treatments and to advise patients to stay active. The aim of this study was to evaluate the management of acute non-specific LBP in the emergency departments (ED).

SETTING

We invited all department chiefs of Swiss EDs and their physician staff to participate in a web-based survey using two clinical case vignettes of patients with acute non-specific LBP presenting to an ED. In both cases, no neurological deficits or red flags were present. Guideline adherence and low-value care was defined based on current guideline recommendations.

RESULTS

In total, 263 ED physicians completed at least one vignette, while 212 completed both vignettes (43% residents, 32% senior/attending physicians and 24% chief physicians). MRI was considered in 31% in vignette 1 and 65% in vignette 2. For pain management, non-steroidal anti-inflammatory drugs, paracetamol and metamizole were mostly used. A substantial proportion of ED physicians considered treatments with questionable benefit and/or increased risk for adverse events such as oral steroids (vignette 1, 12% and vignette 2, 19%), muscle relaxants (33% and 38%), long-acting strong opioids (25% and 33%) and spinal injections (22% and 43%). Although guidelines recommend staying active, 72% and 67% of ED physicians recommended activity restrictions.

CONCLUSION

Management of acute non-specific LBP in the ED was not in agreement with current guideline recommendations in a substantial proportion of ED physicians. Overuse of imaging studies, the use of long-acting opioids and muscle relaxants, as well as recommendations for activity and work restrictions were prevalent and may potentially be harmful.

Evaluation of a blended learning approach on stratified care for physiotherapy bachelor students

BACKGROUND

Stratified models of care are valuable for addressing psychosocial factors which influence the outcome of patients with musculoskeletal disorders. Introducing such models in undergraduate training has the potential to propagate this knowledge with evidence and foster its implementation. The objective of this paper is to explore the perception and changes in the fear-avoidance beliefs of physiotherapy students participating in a developed blended learning course on stratified care.

METHODOLOGY

A mixed-methods with a convenient sample of two consecutive cohorts were given a blended learning course on stratified care for patients with low back pain. The blended learning course comprised scientific rudiments and application of stratified care in clinical practice conceptualised using the KERN' 6-step approach. The exam scores, perceptions, performance on self-reflection-tests and pre- and post-scores on The Tampa Scale for Kinesiophobia for Physiotherapists' (TSK-PT) were obtained. After gaining clinical experience, participants were invited to discuss their clinical experiences and perceptions in workshops. The quantitative data was analysed explorative-descriptively. The qualitative data was analysed following an inductive coding system with constant comparisons.

RESULTS

Ninety-one participants consented to the evaluation (mean age = 22.9 ± 1.6 years), 66% were female. Exam scores correlated with time spent in training (r = 0.30) and scores on self-reflection-tests 1 and 2 (r = 0.40 and r = 0.41). Participants in both cohorts described the learning resources as promoting their interest in the subject (72% and 94%), up-to-date (91% and 93%) and helpful (91% and 97%). The fear-avoidance scores for participants decreased from 53.5 (± 9.96) to 40.1 (± 12.4) with a large effect size (d = 1.18). The regression model [F (2, 49) = 1151.2, p < 0.001] suggests that pre-TSK-PT and the interest of participants in the training predicted post-TSK-PT. The workshop participants (n = 62) all worked in clinical practice. Emerging from the analysis were 4 categories (evolving to maturity in practice, perceiving determinants of stratified care, strategising for implementation and adopting an outlook for future practice).

CONCLUSION

The quality of engagement in learning, training strategy and interest in the subject contributes immensely to learning outcomes. This blended learning course was successful in reducing kinesiophobia and influencing the participants' attitude towards care with the potential of being translated into long-term practice.

How Do Physiotherapists Explain Influencing Factors to Chronic Low Back Pain? A Qualitative Study Using a Fictive Case of Chronic Non-Specific Low Back Pain

BACKGROUND

While pain is influenced by multiple factors including psychosocial factors, previous research has shown that physiotherapists still favour a biomedical approach.

PURPOSE

To evaluate: (1) how physiotherapists explain the patient's chronic non-specific low back pain (LBP); (2) whether physiotherapists use one or multiple influencing factors, and (3) whether these factors are framed in a biopsychosocial or biomedical approach.

MATERIALS AND METHODS

This exploratory qualitative study uses a vignette depicting chronic non-specific LBP and employs a flexible framework analysis. Physiotherapists were asked to mention contributing factors to the pain based on this vignette. Five themes were predefined ("Beliefs", "Previous experiences", "Emotions", "Patients behaviour", "Contextual factors") and explored.

RESULTS

Physiotherapists use very brief explanations when reporting contributing factors to chronic pain (median 13 words). Out of 670 physiotherapists, only 40% mentioned more than two different themes and 2/3rds did not see any link between the patients' misbeliefs and pain. Only a quarter of the participants mentioned the patient's worries about pain and movement, which is considered to be an important influencing factor.

CONCLUSION

The lack of a multifactorial approach and the persistent biomedical beliefs suggest that it remains a challenge for physiotherapists to fully integrate the biopsychosocial framework into their management of chronic LBP.

Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines?

BACKGROUND

Clinical practice guidelines promote bio-psychosocial management of patients suffering from low back pain (LBP). The objective of this study was to examine the current knowledge, attitudes and beliefs of physiotherapists about a guideline-adherent approach to LBP and to assess the ability of physiotherapists to recognise signs of a specific LBP in a clinical vignette.

METHODS

Physiotherapists were recruited to participate in an online study. They were asked to indicate whether they were familiar with evidence-based guidelines and then to fill in the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ), as well as questions related to two clinical vignettes.

RESULTS

In total, 527 physiotherapists participated in this study. Only 38% reported being familiar with guidelines for the management of LBP. Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work. Only half of the physiotherapists recognised the signs of a specific LBP.

CONCLUSIONS

The high proportion of physiotherapists unfamiliar with guidelines and demonstrating attitudes and beliefs not in line with evidence-based management of LBP is concerning. It is crucial to develop efficient strategies to enhance knowledge of guidelines among physiotherapists and increase their implementation in clinical practice.

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

The Flares of Low back pain with Activity Research Study (FLAReS): study protocol for a case-crossover study nested within a cohort study

BACKGROUND

Although it is generally accepted that physical activity and flares of low back pain (LBP) are related, evidence for the directionality of this association is mixed. The Flares of Low back pain with Activity Research Study (FLAReS) takes a novel approach to distinguish the short-term effects of specific physical activities on LBP flares from the cumulative effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. The first aim is to estimate the short-term effects (≤ 24 h) of specific physical activities on LBP flares among Veterans in primary care in the Veterans Affairs healthcare system. The second aim is to estimate the cumulative effects of specific activities on LBP-related functional limitations at 1-year follow-up.

METHODS

Up to 550 adults of working age (18-65 years) seen for LBP in primary care complete up to 36 "Scheduled" surveys over 1-year follow-up, and also complete unscheduled "Flare Window" surveys after the onset of new flares. Each survey asks about current flares and other factors associated with LBP. Surveys also inquire about activity exposures over the 24 h, and 2 h, prior to the time of survey completion (during non-flare periods) or prior to the time of flare onset (during flares). Other questions evaluate the number, intensity, duration, and/or other characteristics of activity exposures. Other exposures include factors related to mood, lifestyle, exercise, concurrent treatments, and injuries. Some participants wear actigraphy devices for weeks 1-4 of the study. The first aim will examine associations between 10 specific activity categories and participant-reported flares over 1-year follow-up. The second aim will examine associations between the frequency of exposure to 10 activity categories over weeks 1-4 of follow-up and long-term functional limitations at 12 months. All analyses will use a biopsychosocial framework accounting for potential confounders and effect modifiers.

DISCUSSION

FLAReS will provide empirically derived estimates of both the short-term and cumulative effects of specific physical activities for Veterans with LBP, helping to better understand the role of physical activities in those with LBP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04828330 , registered April 2, 2021.

The impact of physical therapist attitudes and beliefs on the outcomes of patients with low back pain

BACKGROUND

Low back pain (LBP) is a common problem that places a major burden on individuals and society. It has been proposed that patients treated by biomedically oriented clinicians will have worse outcomes than those treated by biopsychosocially oriented clinicians.

OBJECTIVE

To investigate the impact of physical therapist LBP related attitudes and beliefs on the outcomes of patients with LBP.

DESIGN

Retrospective cohort design.

METHOD

United States based physical therapists utilizing the Focus on Therapeutic Outcomes, Inc. (FOTO) database were surveyed using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT). Outcomes were measured using average Computerized Lumbar Functional Scale change scores (CLFS) and CLFS residual scores.

RESULTS

Analysis was performed on outcome data from 78 physical therapist and included 2345 patients. HC-PAIRS was a univariate predictor of average CLFS change scores and average CLFS residual scores. PABS-PT Biomedical subscale was a univariate predictor of average CLFS change scores. After adjusting for confounding variables, higher HC-PAIRS scores and PABS-BM scores were associated with a greater change in average CLFS score, and higher PABS-BM scores were associated with higher CLFS residual scores.

CONCLUSION

Physical therapists who believed in a stronger relationship between pain and disability had improved patient outcomes.

Turkish version of health care providers' pain and impairment relationship scale: Reliability and validity

PURPOSE

To develop the Turkish version of the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS-TR) by conducting the linguistic and cultural adaptation and to examine the psychometric properties and reliability of the adapted version.

METHODS

A double back-translation procedure was used to translate the questionnaire. Participants received an online survey package with the HC-PAIRS-TR, the Turkish version of Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT-TR), and Turkish Version of the Tampa Scale for Kinesiophobia (TSK-TR). Cronbach's alpha coefficient and item analysis were used to evaluate internal consistency. Intraclass correlation coefficient (ICC) was used to determine the test-retest reliability. Confirmatory factor analysis (CFA) and Rasch Analysis were performed.

RESULTS

The study was conducted with 153 physiotherapists practicing in Turkey. Cronbach's alpha was 0.81. Test-retest reliability was high (ICC = 0.85, p < 0.001), the standard error of measurement was 4.96 (0.94% of mean), and minimal detectable change was 13.75 (26.06% of mean). HC-PAIRS-TR scores correlated significantly with scores for the biomedical factor of the PABS-PT-TR (r = 0.52, p = 0.00), biopsychosocial factor of PABS-PT-TR (r = 0.32, p = 0.00), and TSK-TR (r = 0.52, p = 0.00). According to CFA and Rasch Analysis, the 12 items version of HC-PAIRS-TR fits the one-factor model excellently.

CONCLUSION

The HC-PAIRS-TR appears to be a reliable and valid questionnaire to measure Turkish physiotherapists' beliefs and attitudes about the relationship between low back pain and impairment. Future studies might be planned to validate this questionnaire for other health care providers.

Attitudes and beliefs on low back pain in physical therapy education: A cross-sectional study

BACKGROUND

Prescription behavior in low back pain (LBP) differs between physical therapists with a biomedical versus a biopsychosocial belief, despite the presence of clinical guidelines.

OBJECTIVE

To examine (1) the beliefs of physical therapy students and their adherence to clinical LBP guidelines in Belgium and the Netherlands; (2) whether the beliefs and attitudes of physical therapy students change during education; (3) whether beliefs are related to guideline adherence; (4) whether beliefs and attitudes differ with or without a personal history of LBP.

METHODS

A cross-sectional design included students in the 2nd and 4th year of physical therapy education in 6 Belgian and 2 Dutch institutions. To quantify beliefs, the Pain Attitudes and Beliefs Scale, the Health Care Providers' Pain and Impairment Relationship Scale, and a clinical case vignette were used.

RESULTS

In total, 1624 students participated. (1) Only 47% of physical therapy students provide clinical guidelines' consistent recommendations for activity and 16% for work. (2) 2nd year students score higher on the biomedical subscales and lower on the psychosocial subscale. 4th year students make more guideline consistent recommendations about work and activity. (3) Students with a more biopsychosocial belief give more guideline adherent recommendations. (4) Personal experience with LBP is not associated with different beliefs or attitudes.

CONCLUSIONS

A positive shift occurs from a merely biomedical model towards a more biopsychosocial model from the 2nd to the 4th year of physical therapy education. However, guideline adherence concerning activity and work recommendations remains low.

Knowledge and attitudes toward musculoskeletal pain neuroscience of manual therapy postgraduate students in the Netherlands

BACKGROUND

Health care practitioners' knowledge and attitudes influence patients' beliefs and health outcomes in musculoskeletal (MSK) pain. It is unclear to what extent physiotherapists undertaking a postgraduate master in manual therapy (MT students) possess the knowledge and attitudes toward pain neuroscience to be able to apply the biopsychosocial model in patients with MSK pain.

OBJECTIVES

The aim of this study was to assess the knowledge and attitudes toward pain neuroscience in MT students.

DESIGN

A cross-sectional study.

METHOD

Self-reported knowledge and attitudes were measured among students (n = 662) at baseline and in all years of the MT postgraduate programs in the Netherlands. The Knowledge and Attitudes of Pain questionnaire (KNAP) was used as a primary measure. Difference in KNAP-scores between baseline (0), year 1, year 2 and year 3 was tested using a one-way ANOVA (hypothesis: 0 < 1<2 < 3). A two factor ANOVA was used to determine the interaction effect of focused pain education and year in the curriculum with KNAP.

RESULTS

There was an overall significant difference of KNAP scores with a medium effect size (F(3, 218.18) = 13.56, p < .001, ω² = 0.059). Differences between years ranged from small to medium. Interaction effect of knowledge and attitudes and focused pain education was significant with a small effect size (F(6) = 2.597, p = .017, ω² = 0.012). Sensitivity analyses were consistent with the main results.

CONCLUSIONS

Positive differences in knowledge and attitudes toward pain neuroscience in MT students occur between the progressing years of the curriculum. Differences may be related to the provision of focused pain education.

Communication skills in the context of psychological flexibility: training is associated with changes in responses to chronic pain in physiotherapy students in Spain

Introduction

The aim of this study is to explore the effectiveness of a training programme aimed at managing patients' chronic pain in physiotherapy students in Spain. The programme addressed providing them with efficient skills to manage patients' chronic pain from psychological flexibility (PF) perspective.

Methods

The programme integrates communication skills training into PF-based training. It sought to contribute to better recognise the role of psychosocial factors in chronic pain and to better promote adherence to treatment. This is an observational study with a pre- and post-training programme design and a 2-month follow-up. A total of 35 physiotherapy students, divided into three groups, participated in a 10-hour training course. Training focused on three areas: (1) communication skills, (2) therapeutic adherence and (3) managing distress and pain. The three areas were addressed from the PF point of view. Impact of training was measured through standardised questionnaires that assessed attitudes towards chronic pain, an ad hoc questionnaire that assessed responses to difficult communicative situations and a training satisfaction scale.

Results

Final analyses showed that attitudes changed significantly after training, biomedical attitude scores decreased and biopsychosocial attitude increased, while pain was considered less disabling, and informed empathic responses in communication situations increased. These changes were maintained at 2-month follow-up. Satisfaction with the training was high.

Conclusion

We conclude that a brief training programme based on the PF model may help students develop a more comprehensive approach and improve their skills for managing chronic pain.

A proof-of-concept study on the impact of a chronic pain and physical activity training workshop for exercise professionals

OBJECTIVES

Physical activity is essential for long-term chronic pain management, yet individuals struggle to participate. Exercise professionals, including fitness instructors, and personal trainers, are preferred delivery agents for education and instruction on chronic pain, physical activity, and strategies to use adherence-promoting behavioral skills. However, exercise professionals receive no relevant training during certification or continuing education opportunities to effectively support their participants living with chronic pain. Based on the ORBIT model for early pre-efficacy phases of development and testing of new behavioral treatments, the present Phase IIa proof-of-concept study was conducted. The purpose was to examine the impacts of a newly developed chronic pain and physical activity training workshop on psychosocial outcomes among exercise professionals. Outcomes included knowledge and attitudes regarding chronic pain, attitudes and beliefs about the relationship between pain and impairment, and self-efficacy to educate and instruct participants with chronic pain.

METHODS

Forty-eight exercise professionals (M _age=44.4±11.0 years) participated in a three-hour, in-person workshop that was offered at one of four different locations. Participants completed pre- and post-workshop outcome assessment surveys.

RESULTS

Mixed MANOVA results comparing time (pre- versus post-workshop) by workshop location (sites 1 to 4) illustrated a significant within-subjects time effect (p<0.001). All outcomes significantly improved from pre- to post-workshop (p's<0.001), demonstrating large effect sizes (partial eta-squared values ranging from 0.45 to 0.59).

CONCLUSIONS

Findings offer early phase preliminary support for the effectiveness of the chronic pain and physical activity training workshop for exercise professionals. Based on ORBIT model recommendations, findings warrant future phased testing via a pilot randomized clinical trial as well as testing for impacts that trained professionals have on activity adherence among their clients living with chronic pain. Eventual workshop adoption by exercise professional certification organizations would ensure widespread and sustainable access to qualified exercise professionals to help individuals engage in physical activity. By increasing the capacity of available exercise professionals to deliver effective support, active individuals could better manage their chronic pain and live well.

Biomedical Beliefs Explain the Clinical Decisions Made by Exercise-Based Practitioners for People With Chronic Low Back Pain

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

This study surveyed the attitudes and beliefs of physiotherapists and accredited exercise physiologists (AEP) toward chronic low back pain (CLBP), in Australia. The objective of this study was to investigate the effect of biomedical and biopsychosocial attitudes and beliefs toward CLBP on clinical decision making in exercise-based practitioners.

SUMMARY OF BACKGROUND DATA

The attitudes and beliefs of AEPs toward CLBP have not been studied. Literature regarding physiotherapists suggests a biomedical approach leading to more conservative treatment and on occasion, treatment going against practice guidelines.

METHODS

Seventy five AEPs and 75 physiotherapists were surveyed using the pain attitudes and beliefs scale for physiotherapists, which consists of both a biomedical and biopsychosocial subscale. Clinical decision making was assessed using two patient vignettes.

RESULTS

AEPs held higher biomedical beliefs compared with physiotherapists. No between-group differences were observed on the biopsychosocial subscale. Indeed, biomedical attitudes and beliefs did explain clinical decision making with higher scores reflecting a more conservative approach. However, biomedical beliefs influenced decision making regardless of profession.

CONCLUSION

Biomedical attitudes and beliefs regarding CLBP influence clinical decision making in exercise-based practitioners, regardless of profession. AEPs reported higher biomedical scores, suggesting more frequent choice of conservative care. Thus, patients may receive inconsistent care and advice from practitioners within the same field. Based on clinical practice guidelines and the positive associations on clinical decision making of the biopsychosocial model, it is necessary to understand how best to provide exercise-based practitioners with education on how to apply a biopsychosocial approach to CLBP.Level of Evidence: 3.

Development of Prediction Model for the Prognosis of Sick Leave Due to Low Back Pain

OBJECTIVE

The aim of this study was to develop a prediction model for the prognosis of sick leave due to low back pain (LBP).

METHODS

This is a cohort study with 103 employees sick-listed due to non-specific LBP and spinal disc herniation. A prediction model was developed based on questionnaire data and registered sick leave data with follow up of 180 days.

RESULTS

At follow up 31 (30.1%) employees were still sick-listed due to LBP. Forward selection procedure resulted in a model with: catastrophizing, musculoskeletal work load, and disability. The explained variance was 27.3%, calibration was adequate and discrimination was fair with area under the ROC-curve (AUC) = 0.761 (interquartile range [IQR]: 0.755-0.770).

CONCLUSION

The prediction model of this study can adequately predict LBP sick leave after 180 days and could be used for employees sick listed due LBP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Knowledge of psychosocial factors associated with low back pain amongst health science students: a scoping review

Background

Low back pain is a burden worldwide and biological, psychological, and social mechanisms play a role in its development and persistence. Current guidelines support care using the biopsychosocial model. However, biomedical constructs dominate clinician training, and it is unknown the extent to which health science students understand the psychosocial determinates of a patient’s low back pain. Therefore, the aim of this scoping review is to report health science students’ current knowledge of psychosocial factors associated with low back pain.

Methods

A scoping review framework was used to search electronic databases for research examining health science students’ knowledge of psychosocial factors associated with low back pain. The nature and findings of the studies are highlighted using the data charting tool. Each study was analyzed to determine the type of outcome measurement used. Scores were compared to minimum accepted scores, between disciplines, as education advanced, and after educational modules.

Results

Fourteen studies published between 2004 and 2019 were identified. Seven healthcare disciplines were represented.

In total, 12 different measurement tools were utilized. In 9 studies students demonstrated inadequate knowledge of psychosocial factors associated with low back pain. Three tools compared disciplines and nationalities. Three tools were associated with practice behavior. Eight studies showed improvement as students’ education advanced, and 3 studies demonstrated improvements in knowledge after implementation of pain education modules of varied lengths. Of those, two showed significant improvement.

Conclusions

Health science students in these studies had substandard understanding of psychosocial factors associated with low back pain. Dedicated pain education has the potential to improve low back pain understanding, resulting in more guideline appropriate care recommendation.

Pain Intensity And Attribution Mediate The Impact Of Patient Weight And Gender On Activity Recommendations For Chronic Pain

BACKGROUND AND PURPOSE

Despite the notable benefits of physical activity for chronic pain, a large proportion of patients with chronic pain report that they do not receive activity-related recommendations from their providers. Research suggests that patient factors such as weight and gender influence activity-related recommendations for chronic pain. Research also suggests that appraisals of the intensity and cause of pain may explain these weight and gender effects. We investigated the influence of patient weight and gender on observers' likelihood of recommending activity-related treatments for pain. We also explored the mediating effects of observers' ratings of pain severity and the extent to which pain was due to medical and lifestyle factors (pain attribution).

PATIENTS AND METHODS

Healthy young adults (N=616; 76% female) viewed videos (Ghent Pain Videos of Daily Activities) and vignettes of 4 patients with chronic back pain performing a standardized functional task. Patients varied by gender (female, male) and weight (normal, obese), but were otherwise equivalent on demographic characteristics and pain behaviors. Participants rated how much pain they perceived the patients to be experiencing, the extent to which they attributed the pain to medical and lifestyle factors, and their likelihood of recommending exercise, physical therapy (PT), and rest.

RESULTS

Patient weight and gender significantly interacted to influence exercise, PT, and rest recommendations. Both pain intensity and pain attribution mediated the relationships between patient weight and activity recommendations; however, these mediation effects differed across gender and recommendation type.

CONCLUSION

Patient weight and gender influenced laypeople's activity recommendations for chronic pain. Moreover, the results suggest that observers' perceptions of pain intensity and pain attributions are mechanisms underlying these effects. If these findings are replicated in providers, interventions may need to be developed to reduce provider biases and increase their recognition of the benefits of physical activity for chronic pain.

The Fear Reduction Exercised Early (FREE) approach to management of low back pain in general practice: A pragmatic cluster-randomised controlled trial

BACKGROUND

Effective and cost-effective primary care treatments for low back pain (LBP) are required to reduce the burden of the world's most disabling condition. This study aimed to compare the clinical effectiveness and cost-effectiveness of the Fear Reduction Exercised Early (FREE) approach to LBP (intervention) with usual general practitioner (GP) care (control).

METHODS AND FINDINGS

This pragmatic, cluster-randomised controlled trial with process evaluation and parallel economic evaluation was conducted in the Hutt Valley, New Zealand. Eight general practices were randomly assigned (stratified by practice size) with a 1:1 ratio to intervention (4 practices; 34 GPs) or control group (4 practices; 29 GPs). Adults presenting to these GPs with LBP as their primary complaint were recruited. GPs in the intervention practices were trained in the FREE approach, and patients presenting to these practices received care based on the FREE approach. The FREE approach restructures LBP consultations to prioritise early identification and management of barriers to recovery. GPs in control practices did not receive specific training for this study, and patients presenting to these practices received usual care. Between 23 September 2016 and 31 July 2017, 140 eligible patients presented to intervention practices (126 enrolled) and 110 eligible patients presented to control practices (100 enrolled). Patient mean age was 46.1 years (SD 14.4), and 46% were female. The duration of LBP was less than 6 weeks in 88% of patients. Primary outcome was change from baseline in patient participant Roland Morris Disability Questionnaire (RMDQ) score at 6 months. Secondary patient outcomes included pain, satisfaction, and psychosocial indices. GP outcomes included attitudes, knowledge, confidence, and GP LBP management behaviour. There was active and passive surveillance of potential harms. Patients and outcome assessors were blind to group assignment. Analysis followed intention-to-treat principles. A total of 122 (97%) patients from 32 GPs in the intervention group and 99 (99%) patients from 25 GPs in the control group were included in the primary outcome analysis. At 6 months, the groups did not significantly differ on the primary outcome (adjusted mean RMDQ score difference 0.57, 95% CI -0.64 to 1.78; p = 0.354) or secondary patient outcomes. The RMDQ difference met the predefined criterion to indicate noninferiority. One control group participant experienced an activity-related gluteal tear, with no other adverse events recorded. Intervention group GPs had improvements in attitudes, knowledge, and confidence compared with control group GPs. Intervention group GP LBP management behaviour became more guideline concordant than the control group. In cost-effectiveness, the intervention dominated control with lower costs and higher Quality-Adjusted Life Year (QALY) gains. Limitations of this study were that although adequately powered for primary outcome assessment, the study was not powered for evaluating some employment, healthcare use, and economic outcomes. It was also not possible for research nurses (responsible for patient recruitment) to be masked on group allocation for practices.

CONCLUSIONS

Findings from this study suggest that the FREE approach improves GP concordance with LBP guideline recommendations but does not improve patient recovery outcomes compared with usual care. The FREE approach may reduce unnecessary healthcare use and produce economic benefits. Work participation or health resource use should be considered for primary outcome assessment in future trials of undifferentiated LBP.

TRIAL REGISTRATION

ACTRN12616000888460.

Low back pain

Low back pain affects individuals of all ages and is a leading contributor to disease burden worldwide. Despite advancements in assessment and treatment methods, the management of low back pain remains a challenge for researchers and clinicians alike. One reason for the limited success in identifying effective treatments is the large variation in the manifestations, possible causes, precipitating and maintaining factors, course, prognosis and consequences in terms of activity interference and quality of life. However, despite these challenges, steady progress has been achieved in the understanding of back pain, and important steps in the understanding of the psychological and social risk factors, genetics and brain mechanisms of low back pain have been made. These new findings have given impetus to the development of new diagnostic procedures, evidence-based screening methods and more targeted interventions, which underscore the need for a multidisciplinary approach to the management of low back pain that integrates biological, psychological and social aspects.

The type and pain provoking nature of exercise prescribed for low back pain: A survey of Australian health professionals

OBJECTIVES

To explore the type of exercise prescribed by Australian health professionals for LBP, and whether the exercises prescribed are pain-free or into pain.

METHODS

A survey of physiotherapists and exercise physiologists was conducted from all states/territories in Australia. The survey contained two chronic LBP vignettes with different pain mechanisms (dominant nociceptive or central sensitisation pain) and one acute LBP vignette. Respondents were asked if they would prescribe advice to stay active and exercise. If exercise was prescribed, respondents were asked to specify the type and pain provoking nature (exercise with no pain, exercise to the start of pain, exercise with pain at a tolerable level or exercise irrespective of pain).

RESULTS

The response rate was 17%(218/1276). Most respondents prescribed advice to stay active(≥95%) and exercise(≥90%) for all vignettes. Irrespective of the vignette, several exercises were prescribed [aerobic (57-85% of clinicians), motor control (62-84% of clinicians), range of motion (72-75% of clinicians)]. Strengthening exercise was prescribed more for chronic(>60%) than acute LBP(23%). Irrespective of the exercise, between 20 and 25% of respondents prescribed pain-free exercise, between 71 and 79% of respondents prescribed exercise into pain, and ≤4% prescribed exercise irrespective of pain for acute and chronic LBP.

CONCLUSIONS

Several exercises are prescribed for LBP, irrespective of pain mechanism or duration, with more clinicians prescribing strengthening exercise for chronic than acute LBP. Most clinicians prescribed exercise into pain for acute and chronic LBP, irrespective of the exercise. Further research should determine which exercises are beneficial based on pain mechanism and duration, and whether exercise into pain should be prescribed for LBP.

Changes in pain knowledge, attitudes and beliefs of osteopathy students after completing a clinically focused pain education module

Background

Chronic pain is a substantial burden on the Australian healthcare system with an estimated 19.2% of Australians experiencing chronic pain. Knowledge of the neurophysiology and multidimensional aspects of pain is imperative to ensure health professionals apply a biopsychosocial approach to pain. Questionnaires may be used to assess learner changes in neurophysiology knowledge and beliefs and attitudes towards pain after education interventions.

The aim of this study was to evaluate changes in pain neurophysiology knowledge, beliefs and attitudes following a 12 week clinically-focused pain module in year 3 osteopathy students as measured by the Neurophysiology of Pain (NPQ) Questionnaire and Health Care Providers Pain and Impairment Relationship scale (HC-PAIRS).

Methods

A pre-post design was utilised. Learners completed a demographic information survey pre-module, and completed the NPQ & HC-PAIRS prior to undertaking, and after completing, a twelve week clinically-focused pain module.

Results

Learners (n = 55) completed the NPQ & HC-PAIRS at both time points. The median NPQ score was significantly increased with a large effect size (p < 0.001, z = − 5.71, r = 0.78) following the completion of the module. In contrast, the HC-PAIRS total score was significantly increased after the completion of the module (p < 0.01, z = − 6.95, r = 0.91) suggesting an increase in negative pain attitudes and beliefs. Results indicate that a clinically-focused pain module can increase pain neurophysiology knowledge. However the HC-PAIRS results suggest an increase in negative pain attitudes and beliefs. The HC-PAIRS questionnaire was developed for use with chronic low back pain attitudes & beliefs in practitioners, rather than pre-clinical students. Students were provided with general principles of pain management, rather than condition specific pain management. This study is the first comparing pain neurophysiology knowledge and changes in attitudes and beliefs towards pain pre-post a clinically-focused pain module using the NPQ & HC-PAIRS.

Conclusions

There was a significant improvement in NPQ score after the 12 week clinically-focused pain module. The HC-PAIRS result was paradoxical and may reflect issues with the module design or the measurement tool. The module duration is longer than that reported in the literature and demonstrates effectiveness in increasing pain neurophysiology knowledge.

Electronic supplementary material

The online version of this article (10.1186/s12998-018-0212-0) contains supplementary material, which is available to authorized users.

A subgroup analysis to compare patients with acute low back pain classified as per treatment-based classification

OBJECTIVES

The evidence for the effectiveness of interventions targeting acute low back pain (LBP) is suboptimal. It is difficult to identify those patients who are more likely to develop chronic pain and disability after an acute episode of LBP. These shortcomings may be attributed to considering LBP as one homogenous condition.

METHODS

In this quasi-experimental study, we examined and analysed a prospective cohort of 267 patients with first-onset LBP and classified them into one of the groups based on treatment-based classification: direction-specified exercises (Group 2), manipulation (Group 3), stabilization exercises (Group 4), traction (Group 5), and a physician care group (Group 1). Disability and pain were assessed at baseline, after treatment, and at 6 months using the Oswestry Disability Index and the Numerical Rating Scale, respectively. Comparisons were made between the groups, and we predicted measures of disability and pain intensity at 6 months with age, gender, fear avoidance behaviour, centralization phenomenon (CP), expectations about recovery, CP, group classification, baseline pain, and disability.

RESULTS

Analysis showed that all the heterogeneous groups of LBP improved their outcomes with the respective treatment provided. However, when the entire sample was considered as one homogenous group of LBP, the results showed improvement with time (p < 0.05) only and no difference was found between groups (p > 0.05). None of the studied factors, except baseline pain (R = 0.227, R²  = 0.051, p < 0.05), were able to accurately predict the development of chronic pain in our study sample.

CONCLUSION

Though our results showed no differences between the subgroups in the reduction of pain and disability, we conclude that classifying and treating patients with LBP into subgroups based on signs and symptoms produce better outcomes. Baseline pain alone may predict a small percentage of people who may develop chronic pain.

Item response theory evaluation of the biomedical scale of the Pain Attitudes and Beliefs Scale

OBJECTIVES

The assessment of health care professionals' attitudes and beliefs towards musculoskeletal pain is essential because they are key determinants of their clinical practice behaviour. The Pain Attitudes and Beliefs Scale (PABS) biomedical scale evaluates the degree of health professionals' biomedical orientation towards musculoskeletal pain and was never assessed using item response theory (IRT). This study aimed at assessing the psychometric performance of the 10-item biomedical scale of the PABS scale using IRT.

METHODS

Two cross-sectional samples (BeBack, n = 1016; DABS; n = 958) of health care professionals working in the UK were analysed. Mokken scale analysis (nonparametric IRT) and common factor analysis were used to assess dimensionality of the instrument. Parametric IRT was used to assess model fit, item parameters, and local reliability (measurement precision).

RESULTS

Results were largely similar in the two samples and the scale was found to be unidimensional. The graded response model showed adequate fit, covering a broad range of the measured construct in terms of item difficulty. Item 3 showed some misfit but only in the DABS sample. Some items (i.e. 7, 8 and 9) displayed remarkably higher discrimination parameters than others (4, 5 and 10). The scale showed satisfactory measurement precision (reliability > 0.70) between theta values -2 and +3.

DISCUSSION

The 10-item biomedical scale of the PABS displayed adequate psychometric performance in two large samples of health care professionals, and it is suggested to assess group-level professionals degree of biomedical orientation towards musculoskeletal pain.

Working Together and Being Physically Active Are Not Enough to Advise Uniformly and Adequately Low Back Pain Patients: A Cross-Sectional Study

The profession of the health-care providers (HCPs) influences their recommendations to the patients. Conversely, interdisciplinarity seeks to challenge such differences, so that the patient receives one single and consistent therapeutic message. Some studies also suggest associations between HCPs life habits and recommendations. Our hypotheses were (1) that despite interdisciplinary work, the profession remains a predictor of recommendations and (2) that HCPs who are more physically active recommend more activity. Three clinical vignettes were presented to a group of experts of low back pain (LBP) (guidelines), and 20 physicians, 22 physiotherapists, and 23 nurses to assess how they evaluate the symptoms and pathologies of LBP patients and how much work and physical activity they recommend. Physical activity was assessed with accelerometers and questionnaires. Some interprofessional differences remained present within an interdisciplinary team. The nurses were more restrictive and further away from the guidelines. The physicians were the most in line with them. The physiotherapists recommend as much physical activity, but less work activity than the physicians. The level of physical activity of the HCPs is not associated with their recommendations. To ensure a clear and unique message, educational actions may be undertaken to promote the biopsychosocial model and clarify the guidelines.

Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?: A Longitudinal Case-Crossover Feasibility Study

STUDY DESIGN

Prospective, longitudinal case-crossover study.

OBJECTIVE

The aim of this study was to determine whether physical activities trigger flare-ups of pain during the course of acute low back pain (LBP).

SUMMARY OF BACKGROUND DATA

.: There exist no evidence-based estimates for the transient risk of pain flare-ups associated with specific physical activities, during acute LBP.

METHODS

Participants with LBP of duration <3 months completed frequent, Internet-based serial assessments at both 3- and 7-day intervals for 6 weeks. At each assessment, participants reported whether they had engaged in specific physical activity exposures, or experienced stress or depression, during the past 24 hours. Participants also reported whether they were currently experiencing a LBP flare-up, defined as "a period of increased pain lasting at least 2 hours, when your pain intensity is distinctly worse than it has been recently." Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for associations between potential triggers during the past 24 hours, and the risk of LBP flare-ups, using conditional logistic regression.

RESULTS

Of 48 participants followed longitudinally, 30 participants had both case ("flare") and control periods and contributed data to the case-crossover analysis. There were 81 flare periods and 247 control periods, an average of 11 periods per participant. Prolonged sitting (>6 hours) was the only activity that was significantly associated with flare-ups(OR 4.4, 95% CI 2.0-9.7; P < 0.001). Having either stress or depression was also significantly associated with greater risk of flare-ups (OR 2.5, 95% CI 1.0-6.0; P = 0.04). In multivariable analyses, prolonged sitting (OR 4.2, 95% CI 1.9-9.1; P < 0.001), physical therapy (PT) (OR 0.4, 95% CI 0.1-1.0; P = 0.05), and stress/depression (OR 2.8, 95% CI 1.2-6.7; P = 0.02) were independently and significantly associated with LBP flare-up risk.

CONCLUSION

Among participants with acute LBP, prolonged sitting (>6 hours) and stress or depression triggered LBP flare-ups. PT was a deterrent of flare-ups.

LEVEL OF EVIDENCE

2.

Factors influencing physiotherapists' attitudes and beliefs toward chronic low back pain: Impact of a care network belonging

OBJECTIVES

To assess the attitudes and beliefs of physiotherapists (PTs) regarding the management of chronic LBP and to investigate the factors which influence them.

METHODS

A cross-sectional study conducted in the French Loire Valley region by a questionnaire sent to the private PTs between June and September 2014. Demographic data and modalities of practices were collected in association with the Pain Attitudes and Beliefs Scale (PABS) which is a specific self-administered questionnaire designed to assess the "biomedical" or "behavioral" (i.e., biopsychosocial) management orientation of PTs toward chronic LBP.

RESULTS

One hundred and sixty-eight of the 704 PTs entirely completed the questionnaire (63% of men, 58% >40 years of age) of whom 15 were involved in a LBP care network. A higher biomechanical score was observed with a higher age and lower with full-time employment, less than 20 years of length of practice and a recent LBP-specific training (p < 0.005). Belonging to a LBP care network was associated with a lower biomedical score (p < 0.01) and a higher biopsychosocial score (p < 0.005).

CONCLUSIONS

Belonging to a LBP care network, which implies closer collaboration with multidisciplinary rehabilitation teams, was the most significant factor associated with higher biopsychosocial beliefs in PTs toward chronic LBP management.

Investigation of four self-report instruments (FABT, TSK-HC, Back-PAQ, HC-PAIRS) to measure healthcare practitioners' attitudes and beliefs toward low back pain: Reliability, convergent validity and survey of New Zealand osteopaths and manipulative physiotherapists

BACKGROUND

Healthcare practitioner beliefs influence advice and management provided to patients with back pain. Several instruments measuring practitioner beliefs have been developed but psychometric properties for some have not been investigated.

AIMS

To investigate internal consistency, test-retest reliability and convergent validity of the Fear Avoidance Beliefs Tool (FABT), the Tampa Scale of Kinesiophobia for Health Care Providers (TSK-HC), the Back Pain Attitudes Questionnaire (Back-PAQ), and the Health Care Pain and Impairment Relationship Scale (HC-PAIRS). A secondary aim was to explore beliefs of New Zealand osteopaths and physiotherapists regarding low back pain.

METHOD

FABT, TSK-HC, Back-PAQ, and HC-PAIRS were administered twice, 14 days apart.

RESULTS

Data from 91 osteopaths and 35 physiotherapists were analysed. The FABT, TSK-HC and Back-PAQ each demonstrated excellent internal consistency, (Cronbach's α = 0.92, 0.91, and 0.91 respectively), and excellent test-retest reliability (lower limit of 95% CI for intraclass correlation coefficient >0.75). Correlations between instruments (Pearson's r = 0.51 to 0.77, p < 0.001) demonstrated good convergent validity. There was a medium to large effect (Cohen's d > 0.47) for mean differences in scores, for all instruments, between professions.

CONCLUSIONS

This study found excellent internal consistency, test-retest reliability and good convergent validity for the FABT, TSK-HC, and Back-PAQ. Previously reported internal consistency, test-retest and convergent validity of the HC-PAIRS were confirmed, and test-retest reliability was excellent. There were significant scoring differences on each instrument between professions, and while both groups demonstrated fear avoidant beliefs, physiotherapist respondent scores indicated that as a group, they held fewer fear-avoidant beliefs than osteopath respondents.

The reassuring potential of spinal imaging results: development and testing of a brief, psycho-education intervention for patients attending secondary care

PURPOSE

To develop and test a standardised method of interpreting spinal imaging findings in a manner designed to reassure patients with low back pain and promote engagement in an active recovery.

METHODS

A five-phase development and testing process involved collaborative working party contributions, informal and formal appraisal of the intervention content by clinicians and consumers, a two-stage online evaluation of the take-home patient resource, and onsite testing.

RESULTS

A total of 12 health professionals and 77 consumers were included in formal evaluative processes at various stages of the development and testing process. Consumers assessed the revised iteration of the take-home resource to be clearer and easier to understand than the original version. We integrated all feedback and evaluation outcomes to develop the final intervention content, which was approved by experienced clinicians and considered safe. We devised a framework to guide delivery of the low-cost clinical intervention and a 10-15-min timeframe was demonstrated to be realistic.

CONCLUSIONS

We have developed, modified, and tested a pragmatic framework for a brief, psychoeducational intervention. We have established face validity and acceptability from key stakeholders and engaged clinicians and are ready to proceed with a pilot feasibility trial.

The Fear Reduction Exercised Early (FREE) approach to low back pain: study protocol for a randomised controlled trial

BACKGROUND

Low back pain (LBP) is a major health issue associated with considerable health loss and societal costs. General practitioners (GPs) play an important role in the management of LBP; however, GP care has not been shown to be the most cost-effective approach unless exercise and behavioural counselling are added to usual care. The Fear Reduction Exercised Early (FREE) approach to LBP has been developed to assist GPs to manage LBP by empowering exploration and management of psychosocial barriers to recovery and provision of evidence-based care and information. The aim of the Low Back Pain in General Practice (LBPinGP) trial is to explore whether patients with LBP who receive care from GPs trained in the FREE approach have better outcomes than those who receive usual care.

METHODS/DESIGN

This is a cluster randomised controlled superiority trial comparing the FREE approach with usual care for LBP management with investigator-blinded assessment of outcomes. GPs will be recruited and then cluster randomised (in practice groups) to the intervention or control arm. Intervention arm GPs will receive training in the FREE approach, and control arm GPs will continue to practice as usual. Patients presenting to their GP with a primary complaint of LBP will be allocated on the basis of allocation of the GP they consult. We aim to recruit 60 GPs and 275 patients (assuming patients are recruited from 75% of GPs and an average of 5 patients per GP complete the study, accounting for 20% patient participant dropout). Patient participants and the trial statistician will be blind to group allocation throughout the study. Analyses will be undertaken on an intention-to-treat basis. The primary outcome will be back-related functional impairment 6 months post-initial LBP consultation (interim data at 2 weeks, 6 weeks and 3 months), measured with the Roland-Morris Disability Questionnaire. Secondary patient outcomes include pain, satisfaction, quality of life, days off from work and costs of care. Secondary GP outcomes include beliefs about pain and impairment, GP confidence, and actual and reported clinical behaviour. Health economic and process evaluations will be conducted.

DISCUSSION

In the LBPinGP trial, we will investigate providing an intervention during the first interaction a person with back pain has with their GP. Because the FREE approach is used within a normal GP consultation, if effective, it may be a cost-effective means of improving LBP care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616000888460 . Registered on 6 July 2016.

Brief biopsychosocially informed education can improve insurance workers' back pain beliefs: Implications for improving claims management behaviours

BACKGROUND: Biopsychosocially informed education is associated with improved back pain beliefs and positive changes in health care practitioners’ practice behaviours.

OBJECTIVE: Assess the effect of this type of education for insurance workers who are important non-clinical stakeholders in the rehabilitation of injured workers.

METHODS: Insurance workers operating in the Western Australian workers’ compensation system underwent two, 1.5 hour sessions of biopsychosocially informed education focusing on understanding and identifying barriers to recovery of injured workers with musculoskeletal conditions. Back pain beliefs were assessed pre-education, immediately post-education and at three-month follow-up (n = 32). Self-reported and Injury Management Advisor-reported assessment of change in claims management behaviours were collected at the three-month follow-up.

RESULTS: There were positive changes in the Health Care Providers’ Pain and Impairment Relationship Scale (p = 0.009) and Back Beliefs Questionnaire (p = 0.049) immediately following the education that were sustained at three-month follow-up. Positive changes in claims management behaviours were supported by self-reported and Injury Management Advisor-reported data.

CONCLUSION: This study provides preliminary support that a brief biopsychosocially informed education program can positively influence insurance workers’ beliefs regarding back pain, with concurrent positive changes in claims management behaviours. Further research is required to ascertain if these changes result in improved claims management outcomes.

Graded group exercise and fear avoidance behavior modification in the treatment of chronic low back pain

BACKGROUND

Approaches in the treatment of general chronic low back pain (CLBP) are multifaceted relative to specific interventions. In the past, passive interventions have commonly been employed with little evidence to support their effectiveness. Recent reviews suggest a focus on active exercises programs that includes pain education and cognitive behavioral therapy.

OBJECTIVE

To investigate the outcomes of CLBP patients and describe the approach in persons undergoing a group spinal rehabilitation program using graded exercise, and operant conditioning.

METHODS

Adult patients with CLBP participated in a twice weekly 90 minute exercise sessions for 8-weeks (n= 201). The program consisted of behavioral education, stretching, aerobic exercises, graded progressive resistance exercise, MedX isotonic strengthening, and functional bending lifting task exercises.

RESULTS

A total of 201 patient records were evaluated where the overall ODI improvement was 13.2% (± 14.0) (p< 0.001). There were significant and clinically meaningful improvements in flexibility, VAS, functional lifting tasks (p< 0.001), and lumbar extension strength (p= 0.01) at 8-week follow-up. Questionnaires were delivered via mail with a 21% return rate revealed sustained improvements.

CONCLUSION

CLBP patients undergoing an 8-week intensive exercise approach incorporating both behavioral and physical conditioning principles showed both significant and clinically significant improvements in this observational case series. Long-term benefits were also seen in both the 6 and 12 month follow-up questionnaires although further investigation is warranted due to limited survey return rate and study design.

Pain-related fear and functional recovery in sciatica: results from a 2-year observational study

OBJECTIVES

The purpose of this study was to explore the associations between pain-related fear, pain disability, and self-perceived recovery among patients with sciatica and disk herniation followed up for 2 years.

PATIENTS AND METHODS

Pain-related fear was measured by the Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire-Physical Activity (FABQ-PA) subscale. Disability was measured by the Maine-Seattle Back Questionnaire. At 2 years, patients reported their sciatica/back problem on a global change scale ranging from completely gone to much worse. No specific interventions regarding pain-related fear were provided.

RESULTS

Complete data were obtained for 372 patients. During follow-up, most patients improved. In those who at 2 years were fully recovered (n=66), pain-related fear decreased substantially. In those who did not improve (n=50), pain-related fear remained high. Baseline levels of pain-related fear did not differ significantly between those who were fully recovered and the rest of the cohort. In the total cohort, the correlation coefficients between the 0-2-year change in disability and the changes in the TSK and the FABQ-PA were 0.33 and 0.38, respectively. In the adjusted regression models, the 0-2-year change in pain-related disability explained 15% of the variance in the change in both questionnaires.

CONCLUSION

Pain-related fear decreased substantially in patients who recovered from sciatica and remained high in those who did not improve. Generally, the TSK and the FABQ-PA yielded similar results. To our knowledge, this is the first study that has assessed pain-related fear in patients who recover from sciatica.

What Messages Do Patients Remember? Relationships Among Patients' Perceptions of Physical Therapists' Messages, Patient Characteristics, Satisfaction, and Outcome

BACKGROUND

Based on a behavioral medicine perspective, modern recommendations for physical therapists treating patients with spinal pain include performing a trustworthy physical examination, conveying the message that back pain is benign, and stressing that activity is a key to recovery. However, little evidence is available on how patients perceive these biopsychosocial messages and how patients' perceptions of these messages relate to their recovery.

OBJECTIVES

The aim of this study was to explore the relationships between perceptions of treatment delivery that are related to an evidence-based approach and psychological factors, treatment outcome, and treatment satisfaction.

DESIGN

A cohort study with 3 measurement points was conducted.

METHODS

Data on 281 participants were collected.

RESULTS

High catastrophizing and lower mood in the participants were correlated to "not perceiving the biopsychosocial message" measured at 6 weeks after treatment start. Participants who did not perceive the biopsychosocial message were at higher risk for disability and had lower treatment satisfaction 6 months after treatment start even when controlling for pretreatment pain intensity. "Not perceiving the biopsychosocial message" was not a mediator for treatment outcome and treatment satisfaction. Physical therapists' treatment orientations or attitudes were not related to the perception of the message by the patients.

LIMITATIONS

There was no measure of actual practice behavior.

CONCLUSIONS

Maladaptive cognitions and negative emotions appear to affect the way information provided during treatment is perceived by patients. The way information is perceived by patients influences treatment outcome and treatment satisfaction. Physical therapists are advised to check that patients with higher levels of catastrophizing and lower mood are correctly perceiving and interpreting a biopsychosocial message.

Brief psychologically informed physiotherapy training is associated with changes in physiotherapists' attitudes and beliefs towards working with people with chronic pain

This study aimed to investigate the impact of a brief psychologically informed physiotherapy training (PIPT) course on physiotherapists' attitudes and beliefs towards working with people with chronic pain. Specifically, the training aimed to help the participants better recognise the role of psychosocial factors in chronic pain and to better target the key processes of the psychological flexibility (PF) model in their treatment interactions. A total of 26 physiotherapists working in an outpatient musculoskeletal (MSK) department participated in the 7-hour training session. A total of 25 participants completed self-report questionnaires on attitudes and beliefs, burnout and PF-relevant processes pre- and post-training. The pre- and post-measures were completed on the day of training. PIPT was associated with significant changes in the expected direction in physiotherapists' attitudes towards treatment of people with chronic pain, including a moderate effect size on the Health Care Provider-Pain and Impairment Relationship Scale (HC-PAIRS) (decreased biomedical scores) and a large effect size on the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) (increased biopsychosocial scores and decreased biomedical scores). In conclusion, brief PIPT could help physiotherapists working in non-specialist centres with complex patients, many of whom present with significant emotional distress and pain-related disability. Further research is required to determine whether the changes in attitudes detected in this study translate into clinical practice and whether changes are maintained over a follow-up period.

[Health care professionals' attitudes and beliefs towards older back pain patients. Analysis of the assessment methods and research gaps]

In recent years, the influence of doctors' and therapists' attitudes and beliefs for the treatment of chronic low back pain patients has been increasingly investigated. Attitudes and beliefs of health care providers have been identified as important contributors for an activity based, guideline-oriented therapeutic approach and different questionnaires were developed to evaluate this interaction. Recent reviews discuss the quality of those questionnaires as well as the impact of attitudes towards therapeutic choices and activity recommendations by health care professionals. This article summarizes these results and illuminates transferability of existing questionnaires to older patients with back pain. A literature review shows that most studies were conducted with physiotherapists and general practitioners. At present the most thoroughly investigated tool for its psychometric validity is the Pain Attitudes and Beliefs Scale (PABS). The PABS could be a suitable instrument for examinations regarding therapist attitudes towards older pain patients by using more age-neutral wording. Concluding from the literature, an additional methodological assessment tool could be the utilization of case vignettes. However, those case vignettes, which had been used in studies in England, should be translated and culturally adapted before its application in Germany. Overall, it must be assumed that attitudes and beliefs of clinicians are also important in the care of older patients in pain. With regards to activity recommendations, ageism and the special situation of older people should also be taken into account including possible risk of falling, multimorbidity, polypharmacy, and cognitive impairment. These topics should all be considered in adapted or newly developed questionnaires for the evaluation of attitudes and beliefs of health care providers regarding back pain in older persons.