A 10-year follow-up of tailored behavioural treatment and exercise-based physiotherapy for persistent musculoskeletal pain

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders (PREVSAM): short term effects of a randomised controlled trial in primary care

PURPOSE

To evaluate short-term effects of the PREVention of Sickness Absence for Musculoskeletal disorders (PREVSAM) model on sickness absence and patient-reported health outcomes.

METHODS

Patients with musculoskeletal disorders were randomised to rehabilitation according to PREVSAM or treatment as usual (TAU) in primary care. Sickness absence and patient-reported health outcomes were evaluated after three months in 254 participants.

RESULTS

The proportion of participants remaining in full- or part-time work were 86% in PREVSAM vs 78% in TAU (p = 0.097). The PREVSAM group had approximately four fewer sickness benefit days during three months from baseline (p range 0.078-0.126). No statistically significant difference was found in self-reported sickness absence days (PREVSAM 12.4 vs TAU 14.5; p = 0.634), nor were statistically significant differences between groups found in patient-reported health outcomes. Both groups showed significant improvements from baseline to three months, except for self-efficacy, and only the PREVSAM group showed significantly reduced depression symptoms.

CONCLUSIONS

The findings suggest that for sickness absence, the PREVSAM model may have an advantage over TAU, although the difference did not reach statistical significance at the p < 0.05 level, and similar positive effects on patient-reported health outcomes were found in both groups. Long-term effects must be evaluated before firm conclusions can be drawn.

Sustainability of cognitive behavioural interventions for chronic back pain: A long-term follow-up

BACKGROUND

There is a significant research gap with respect to the long-term sustainability of psychological treatment effects in chronic pain patients. This study aimed to investigate long-term treatment effects of two psychological treatments: cognitive behavioural therapy (CBT) as a broad-spectrum approach and exposure as a specific intervention for fear-avoidant pain patients.

METHODS

Patients with chronic low back pain were randomized to CBT or exposure in vivo. Long-term follow-up (LTFU) data were available for 64 patients up to 8 years after treatment, with a response rate of 73%. The primary outcomes were pain-related disability and pain intensity and secondary outcomes were emotional distress, psychological flexibility, catastrophizing and pain-related fear. The data analysis was performed with longitudinal multilevel modelling.

RESULTS

Multilevel analyses showed improvements in all primary outcomes as well as all secondary outcomes from pre-treatment to LTFU for both treatments. The mean proportion of cases meeting reliable and clinical improved criteria in all primary outcome was 36% (range: 22%-46%) in the exposure group and 50% (range: 33%-60%) in the CBT group. Dropout analyses revealed significantly higher deterioration rates over time. Pre-treatment to LTFU effect sizes of the primary outcomes ranged from 0.54 to 1.59.

CONCLUSIONS

Our results indicate that the effects of psychological treatments might be stable over several years. Treatment gains for exposure as a stand-alone treatment seem to be of shorter duration than a general CBT intervention. Thus, psychological treatments might offer a promising and sustainable long-term perspective for patients with chronic back pain.

SIGNIFICANCE

The long-term stability of treatment effects is a highly neglected issue despite its inherent importance in the context of chronic pain. This study is the first to investigate treatment effects of cognitive behavioural therapy and in vivo exposure in chronic back pain sufferers up to 8 years after treatment. The findings contribute to an understanding of the sustainability of psychological cognitive behavioural therapy-based intervention effects.

Goal setting in physiotherapy-led adult musculoskeletal care: A scoping review

INTRODUCTION

Goal setting is a key part of rehabilitation across various fields of physiotherapy. It is less clear what evidence exists to underpin its effectiveness and to practically guide its use within musculoskeletal physiotherapy.

OBJECTIVES

This scoping review provides an overview of current research regarding goal setting in adult physiotherapy-led musculoskeletal care with three aims: 1) to identify and analyse any gaps in the literature, 2) to identify relevant features of goal setting theory and 3) to make recommendations for future research. The principal research question was what does the literature tell us about the role of goal setting for adults over the age of 18 with musculoskeletal pain accessing outpatient physiotherapy services?

INCLUSION CRITERIA

The population, concept and context framework was used to define the inclusion criteria. Key definitions were adults over the age of 18 with musculoskeletal conditions, goal setting, and physiotherapy-led interventions.

METHODS

This scoping review followed the guidance set out by the Joanna Briggs Institute Manual for Evidence Synthesis. Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, MEDLINE, American Psychological Association PsycInfo and the Cochrane Database of Systematic Reviews, Protocols and Trials were searched using pre-defined search criteria. Data were extracted from screened full-text articles and presented in basic statistical and narrative form.

RESULTS

41 articles were included in the review. Several broad themes and research methods were identified. The nature of the studies suggested that the clinical application of goal setting is complex and the depth of understanding is limited. Most studies suggested that goal setting is feasible and has a positive impact on outcomes. A common finding was a lack of clear definitions regarding goal setting terminology and approaches. Study samples were generally defined by biomedical categories, suggesting a pathoanatomical approach to researching a cognitive construct. Theoretical underpinning was lacking in many studies. No frameworks guiding goal setting in physiotherapy-led musculoskeletal rehabilitation have been identified.

CONCLUSIONS

Goal setting is a popular tool within musculoskeletal outpatient physiotherapy. Further research is required to clarify its efficacy and provide guidance on its role and application in clinical practice.

Researcher's Perspective on Musculoskeletal Conditions in Primary Care Physiotherapy Units through the International Classification of Functioning, Disability, and Health (ICF): A Scoping Review

(1) Background: Musculoskeletal disorders are the second cause of disability in the world. The International Classification of Functioning Disability and Health (ICF) is a tool for systematically describing functioning. Outcome measures for musculoskeletal disorders and functioning concepts embedded in them have not been described under the ICF paradigm. The objective of this scoping review was to identify ICF categories representing the researcher's perspective and to compare them with the ICF core set for post-acute musculoskeletal conditions. (2) Methods: This review was conducted as follows: (a) literature search using MEDLINE/PubMed, CINAHL, Web of Science, and Scopus databases; (b) study selection applying inclusion criteria (PICOS): musculoskeletal conditions in primary care, application of physiotherapy as a treatment, outcome measures related to functioning, and experimental or observational studies conducted in Western countries during the last 10 years; (c) extraction of relevant concepts; (d) linkage to the ICF; (e) frequency analysis; and (f) comparison with the ICF core set. (3) Results: From 540 studies identified, a total of 51 were included, and 108 outcome measures were extracted. In the ICF linking process, 147 ICF categories were identified. Analysis of data showed that 84.2% of the categories in the ICF core set for post-acute musculoskeletal conditions can be covered by the outcome measures analyzed. Sixty-eight relevant additional ICF categories were identified. (4) Conclusion: Outcome measures analyzed partially represent the ICF core set taken as a reference. The identification of additional categories calls into question the applicability of this core set in primary care physiotherapy units.

Non-pharmacological interventions to promote work participation in people with rheumatic and musculoskeletal diseases: a systematic review and meta-analysis from the EULAR taskforce on healthy and sustainable work participation

OBJECTIVE

To summarise the evidence on effectiveness of non-pharmacological (ie, non-drug, non-surgical) interventions on work participation (sick leave, work status and presenteeism) in people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

A systematic review of randomised controlled trials (RCTs) and longitudinal observational studies (LOS) was performed. Qualitative (RCTs/LOS) and quantitative (RCTs) evidence syntheses were conducted. Mixed-effects restricted maximum likelihood models were used to combine effect estimates, using standardised mean differences (SMDs) as the summary measure for each outcome domain separately, with a negative SMD favouring the intervention over comparator. Subgroup analyses were performed for type of RMD, risk status at baseline regarding adverse work outcomes and intervention characteristics.

RESULTS

Of 10 153 records, 64 studies (37 RCTs and 27 LOS; corresponding to k=71 treatment comparisons) were included. Interventions were mostly conducted in clinical settings (44 of 71, 62%). Qualitative synthesis suggested clear beneficial effects of 7 of 64 (11%) interventions for sick leave, 1 of 18 (6%) for work status and 1 of 17 (6%) for presenteeism. Quantitative synthesis (37 RCTs; k=43 treatment comparisons) suggested statistically significant but only small clinical effects on each outcome (SMD_{sick leave} (95% CI)=-0.23 (-0.33 to -0.13; k=42); SMD_{work status}=-0.38 (-0.63 to -0.12; k=9); SMD_presenteeism=-0.25 (-0.39 to -0.12; k=13)).

CONCLUSION

In people with RMDs, empirical evidence shows that non-pharmacological interventions have small effects on work participation. Effectiveness depends on contextual factors such as disease, population risk status, intervention characteristics and outcome of interest, highlighting the importance of tailoring interventions.

Implementing a behavioral medicine approach in physiotherapy for patients with musculoskeletal pain: a scoping review

Supplemental Digital Content is Available in the Text.

The interventions in the scoping review were in agreement with the definition of behavioral medicine in physiotherapy, but reported behavior change techniques were few.

In intervention research on musculoskeletal pain, physiotherapists often study behavioral and cognitive components. Evidence on applying these components has increased during the past decade. However, how to effectively integrate behavioral and cognitive components in the biopsychosocial management of musculoskeletal pain is challenging. The aim was to study the intervention components and patient outcomes of studies integrating behavioral and cognitive components in physiotherapy, to match the interventions with a definition of behavioral medicine in physiotherapy and to categorize the behavior change techniques targeted at patients with musculoskeletal pain in (1) randomized controlled effect trials or (2) implementation in clinical practice trials. A scoping review was used to conduct this study, and the PRISMA-ScR checklist was applied. Relevant studies were identified from the PubMed, MEDLINE, PsycINFO, CINAHL Plus, and Web of Science Core databases separately for the (1) randomized controlled effect trials and (2) implementation in clinical practice trials. Synthesis for the matching of the patient interventions with the existing definition of behavior medicine in physiotherapy showed that the interventions mostly integrated psychosocial, behavioral, and biomedical/physical aspects, and were thus quite consistent with the definition of behavioral medicine in physiotherapy. The reported behavior change techniques were few and were commonly in categories such as “information of natural consequences,” “feedback and monitoring,” and “goals and planning.” The patient outcomes for long-term follow-ups often showed positive effects. The results of this scoping review may inform future research, policies, and practice.

Resilience and return-to-work pain interventions: systematic review

BACKGROUND

Resilience is a developing concept in relation to pain, but has not yet been reviewed in return-to-work (RTW) contexts.

AIMS

To explore the role of resilience enhancement in promoting work participation for chronic pain sufferers, by reviewing the effectiveness of existing interventions.

METHODS

Resilience was operationalized as: self-efficacy, active coping, positive affect, positive growth, positive reinforcement, optimism, purpose in life and acceptance. Five databases were searched for randomized controlled trials (RCTs) whose interventions included an element of resilience designed to help RTW/staying at work for chronic pain sufferers. Study appraisal comprised the Cochrane risk of bias (RoB) tool and additional quality assessment. Findings were synthesized narratively and between-group differences of outcomes were reported. Heterogeneous PICO (population, intervention, comparator, outcome) elements precluded meta-analysis.

RESULTS

Thirty-four papers from 24 RCTs were included. Interventions varied; most were multidisciplinary, combining behavioural, physical and psychological pain management and vocational rehabilitation. Four found RTW/staying at work improved with intensive multidisciplinary interventions compared with less intensive, or no, treatment. Of these, one had low RoB; three scored poorly on allocation concealment and selective outcome reporting. Four trials had mixed results, e.g. interventions enabling reduced sick leave for people on short-term not long-term leave; 16 showed no improvement. Five trials reported resilience outcomes were improved by interventions but these were not always trials in which RTW improved.

CONCLUSIONS

Effectiveness of resilience interventions for chronic pain sufferers on RTW is uncertain and not as helpful as anticipated. Further agreement on its conceptualization and terminology and that of RTW is needed.

The prevalence of fear avoidance and pain catastrophising amongst patients with chronic neck pain

Background

Cognitive factors impact chronic pain, but the prevalence of fear avoidance (FA) and pain catastrophising (PC) in individuals suffering from chronic neck pain (CNP) has not been investigated in South Africa.

Objectives

To determine the prevalence of FA and PC in patients with CNP at private physiotherapy practices in Johannesburg.

Method

The Tampa Scale for Kinesiophobia-11 (TSK-11) (α = 0.80) and Pain Catastrophising Scale (α = 0.87) self-report questionnaires were used in a cross-sectional study to determine the prevalence of FA and PC, respectively. Descriptive statistics and correlations using Pearson’s or Spearman’s coefficient were conducted between demographic variables and FA and PC. Non-parametric data were tested using the Wilcoxon rank-sum or Kruskal–Wallis test. Cohen’s d-value or r-value measured strength of associations.

Results

A sample of 106 CNP patients with a mean age of 48.7 years (± 14.8) from 25 randomly selected private practices participated in the study. Of the participants, 81% were women (n = 86). Fear avoidance and PC had a prevalence of 25.5% (n = 27) and 15.1% (n = 16), respectively. A positive correlation was found between FA-11-Total and PC-Total (r = 0.684; p = 0.0001) and between FA (TSK-11-Total and TSK-SF (somatic focus)) and PC and its subscales (r ≥ 0.602; p = 0.0001). Participants with a secondary education (26.0 ± 3.4) showed a higher FA than those with tertiary education (21.9 ± 1.5). Effect size was moderate (Cohen’s d = 0.60). Pain intensity correlated positively with both FA (Pearson’s correlation: r = 0.33; p = 0.001) and PC (Spearman’s correlation; r = 0.39; p = 0.0001).

Conclusion

FA and PC affect a number of patients with CNP. A lower level of education was associated with FA and a higher pain intensity was associated with higher FA and PC.

Clinical implications

Identifying FA and PC in patients with CNP is important to facilitate holistic management.

Effects of a behavioral medicine intervention on pain, health, and behavior among community-dwelling older adults: a randomized controlled trial

Purpose

The aim of the study was to evaluate the effects of an intervention, based on a behavioral medicine approach in physical therapy (BMPI), on pain-related disability and physical performance as well as on pain severity, pain catastrophizing, physical activity levels, falls efficacy, and health-related quality of life (HRQL) by comparing the effects to standard care.

Patients and methods

The study was a pragmatic randomized controlled trial with a two-group design and included measurements preintervention and postintervention and a 12-week follow-up. In total, 105 older adults, aged >75 years with chronic musculoskeletal pain living alone at home and dependent on formal care to manage their everyday lives, were included in the study. All statistical analyses were performed using an intention to treat approach.

Results

The intervention, based on a behavioral medicine approach, compared to usual care, had a positive effect on pain-related disability, pain severity, level of physical activity, HRQL, management of everyday life, and self-efficacy.

Conclusion

BMPI can be a suitable evidence-based intervention for community-dwelling older adults, even for those who are very old and frail. BMPI can support and promote an active aging and “age in place” for the target population, which is currently the main goal of all interventions in this field.

The perceptions of older adults living with chronic musculoskeletal pain about participating in an intervention based on a behavioral medicine approach to physical therapy

Background: There is evidence that interventions based on a behavioral medicine approach to physical therapy (BMPI) are beneficial for older adults living with chronic pain; however, knowledge of the perceptions of older people regarding their participation in BMPI is lacking. Aim: The aim of this study was to describe the perceptions of older people about being participants in a home-based BMPI. Methods: Semi-structured interviews were conducted with 12 older adults living with chronic pain and participating in a BMPI. Data were analyzed using qualitative content analysis. Results: The respondents highlighted the importance of the home-based and individualized nature of the intervention. They perceived the support from the physical therapist (PT) as significant for their motivation and goal attainment. The benefits of the intervention were described in physical, psychological, social, and functional terms and as enabling participants to live at home for longer. Conclusion: The results show that participation in a BMPI was perceived as a positive and meaningful experience. Support from a PT is crucial to encouraging behavioral changes. Finally, participation in a BMPI may contribute to the ability of participants to "age in place" for longer.

A behavioral medicine intervention for community-dwelling older adults with chronic musculoskeletal pain: protocol for a randomized controlled trial

BACKGROUND

Chronic musculoskeletal pain is a major health problem among older adults, particularly those who live alone and/or those who are dependent on formal care. Chronic pain is associated with mobility problems, falls, fear of falling, catastrophizing thoughts, and a lower quality of life. Research shows that physical therapy interventions based on behavioral medicine approaches are beneficial for middle-aged adults with chronic pain. However, there appears to be no previous randomized controlled trials (RCTs) based on this theoretical framework that have examined the effect on older adults with chronic musculoskeletal pain who live alone at home and are dependent on formal care to manage their everyday lives. The aim of the planned study is to evaluate the effect of an individually tailored integrated physical therapy intervention based on a behavioral medicine approach compared with the effect of standard care.

METHODS/DESIGN

The planned study is an RCT that will include one intervention and one control group involving a total of 150 adults aged ≥75 years with chronic musculoskeletal pain who live alone at home and are dependent on formal care to manage their everyday lives. The intervention will involve a 12-week home-based individually tailored intervention that will be designed to enhance the participants' ability to perform everyday activities by improving physical function and reducing pain-related disability and beliefs. The control group will be given standard care, including general advice about physical activity. The participants will be assessed at baseline and at 3 and 6 months after baseline. The primary outcome will be pain-related disability and physical performance.

DISCUSSION

The intervention, if effective, will have the potential to be the basis of the first evidence-based guidelines for physical therapists who work with older adults with chronic musculoskeletal pain.