Effect of a simple information booklet on pain persistence after an acute episode of low back pain: a non-randomized trial in a primary care setting

Efficiency of Associating Therapeutic Patient Education with Rehabilitation in the Management of Chronic Low Back Pain: A Randomized Controlled Trial

BACKGROUND

This study aimed to assess the benefits of associating rehabilitation with therapeutic patient education (TPE) to decrease fear-avoidance belief and pain and improve function in adults with chronic low back pain (CLBP).

METHODS

This randomized controlled study included 100 patients with CLBP according to the CONSORT (Consolidated Standards of Reporting Trials) guidelines. The patients were divided into two teams: group A that participated in the TPE in association with rehabilitation and group B that received rehabilitation only. Pain and functional amelioration were assessed initially (T0) and at the end of the program (T1) using a visual analog scale at rest, work, and activity, and the Echelle d'Incapacité Fonctionnelle pour l'Évaluation des Lombalgies scale. Psychological and apprehension and avoidance assessments were also conducted, including the evaluation of depression, anxiety, fear-avoidance belief, and kinesiophobia using the Hospital Anxiety and Depression Scale, Fear-Avoidance Beliefs Questionnaire, and Tampa scale of kinesiophobia scale.

RESULTS

The evaluation of progression initially (T0) and then at the end of the program (T1) revealed a significant reduction in pain at rest (P=0.00) and while working (P=0.00) and doing physical activity (P=0.03); a decrease in anxiety (P=0.03), fear-avoidance belief (P=0.03), and kinesiophobia (P=0.02); and an improvement in function (P=0.00) for patients in group A without amelioration of depression (P=0.15). Concerning group B, we identified a significant regression in pain at rest (P=0.001) and while working (P=0.03) and doing physical activity (P=0.00); depression (P=0.01); fear-avoidance beliefs (P=0.00); and kinesiophobia (P=0.002). Comparison between the groups revealed that associating TPE with rehabilitation resulted in a more significant improvement in function (P=0.00), anxiety (P=0.00), fear-avoidance belief (P=0.00), and kinesiophobia (P=0.00).

CONCLUSION

Associating TPE with rehabilitation improved function and reduced fear, false beliefs, and kinesiophobia of movement in patients with CLBP.

The Effectiveness of Group-Based Core Stability Exercise and Educational Booklet for Hospital Workers in Taiwan with Nonspecific Low Back Pain: A Preliminary Study

To investigate the effectiveness of health promotion strategies for nonspecific low back pain in hospital workers, we compared the therapeutic effects of group-based core stability exercises and an educational booklet. Subjects participated in a 60-min core stability exercise on a weekly basis for 8 weeks (N = 24) or consulted an educational booklet for advice (N = 22). The numerical rating scale (NRS), Oswestry Disability Index (ODI), and the brief version of the World Health Organization’s Quality of Life (WHOQOL-BREF) were used as outcome measures. The ODI, as well as the total score and domains of overall, physical, and psychological health in the WHOQOL-BREF were significantly improved in the exercise group (p < 0.05). The NRS score significantly improved in the booklet group (p < 0.05). The total score, psychological domain, and environmental domain of the WHOQOL-BREF improved significantly in the exercise group compared with the booklet group (p < 0.05). Group-based core stability exercises and educational booklets are helpful to hospital workers in different ways for nonspecific low back pain. In contrast to the pain reduction by the educational booklet, more active participation in group-based core stability exercise can provide a better outcome in the overall quality of life, especially in the psychological and environmental domains of hospital workers.

Usual care including home exercise with versus without spa therapy for chronic low back pain: protocol for the LOMBATHERM' study, a multicentric randomised controlled trial

BACKGROUND

Low back pain is highly prevalent and a major source of disability worldwide. Spa therapy is frequently used to treat low back pain, but the associated level of evidence for efficacy is insufficient. To fill this knowledge gap, this protocol proposes an appropriately powered, prospective, evaluator-blinded, multi-centre, two-parallel-arm, randomised (1:1), controlled trial that will compare spa therapy in addition to usual care including home exercise (UCHE) versus UCHE alone for the treatment of chronic low back pain.

METHODS

Eligible patients (anticipated sample size of 358) will have had low back pain for more than 3 months and scores for pain greater than 40 mm on a visual analogue scale (VAS). Following initial consent for UCHE and baseline evaluations, patients are randomised (1:1) to UCHE alone, or UCHE plus spa therapy (18 days of mud packs, underwater massages, showers and water exercises under medical supervision). Patients in the latter arm will be requested to sign an additional consent form as per Zelen randomisation. Follow-up visits will occur at approximately months 1, 6 and 12 and (along with baseline assessments) will cover changes over time in VAS pain scores, the impact of lower back pain on daily life (the Rolland and Morris Disability Questionnaire (RMDQ)), inappropriate fears and beliefs about lower back pain (the fear, avoidance, belief questionnaire (FABQ)), general quality of life (the Euroqol Group 5 dimension, 5 level questionnaire (EQ-5D-5 L)), Patient Acceptable Symptom State (PASS), consumption of analgesic drugs and nonsteroidal anti-inflammatory drugs (NSAIDs), and overall state of health. Health resource use and days of sick leave (and subsequently the associated costs) will also be recorded. The primary outcome is the presence/absence of a clinically relevant change (improvement of at least 30%) in the VAS score for pain at 6 months.

DISCUSSION

Despite the fact that previous, rather dated recommendations encourage spa therapy for the treatment of low back pain, the current literary corpus is methodologically poor. This protocol has been designed to provide results spanning a thorough range of outcomes at the highest evidence level possible.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03910023. Registered on 10 April 2019.

Measuring the impact of the French version of The Whiplash Book on both treatment approach and fear-avoidance beliefs among emergency physicians. A cluster randomized controlled trial

Background

Whiplash-associated disorders have been the subject of much attention in the scientific literature and remain a major public health problem.

Objective

Measure the impact of a validated information booklet on the fear-avoidance beliefs of emergency physicians and their approach to management regarding the treatment of whiplash-associated disorders.

Methods

A prospective cluster randomized controlled study conducted with a sample of emergency medicine physicians. Fear-avoidance beliefs were measured using The Whiplash Belief Questionnaire (WBQ) and Fear-Avoidance Beliefs Questionnaire (FABQ). We assessed the approach to management based on the prescription of pharmacological and non-pharmacological treatments based on the advice given to patients. The validated information booklet was the French version of The Whiplash Book. A set of questionnaires was sent to participants pre- and post-intervention. The experimental intervention was the provision of The Whiplash Book. The control arm did not receive any training or information.

Results

Mean fears and beliefs scores on inclusion were high: WBQ = 19.09 (± 4.06); physical activity FABQ = 11.45 (± 4.73); work FABQ = 13.85 (± 6.70). Improvement in fear-avoidance beliefs scores being greater in the intervention group was further confirmed by the variation in WBQ (-20 [-32; -6] vs. -6 [-16; 9]; p = 0.06), physical activity FABQ (-70 [-86; -50] vs. -15 [-40; 11]; p < 0.001), and work FABQ (-40 [-71; 0] vs. 0 [-31; 50]; p = 0.02). The emergency physicians' initial approach to management was not consistent with current guidelines. Reading the French version of The Whiplash Book could contribute to changing their approach to management in several areas on intra-group analysis.

Conclusion

The French version of The Whiplash Book positively influenced fear-avoidance beliefs among emergency physicians.

[Effectiveness of a risk-tailored short intervention to prevent chronic low back pain : A cluster-randomized study in general practice]

BACKGROUND

A subgroup of patients with acute low back pain (LBP) will develop chronic LBP. Risk factors summarized as yellow flags are fear-avoidance beliefs, depression, catastrophizing, and work-related problems.

OBJECTIVE

The aim was to evaluate the effectiveness of screening for yellow flags in general practice followed by a risk-tailored group intervention compared to care as usual.

METHODS

This is a cluster-randomized controlled trial in 35 general practices with 354 patients with acute LBP. Information or a standardized group intervention was offered to patients in the intervention group according to the screening algorithm with a short questionnaire for physical and psychosocial risk factors for chronic LBP. Standardized group information contained education concerning back pain and strategies for physical activities and planning of actions. Primary outcome was functional capacity assessed after 6 and 12 months with a questionnaire. Secondary outcomes were pain severity, fear avoidance beliefs, depression score, self-rated health and health service utilization.

RESULTS

The intervention had no clinically relevant effect on the primary outcome functional capacity and secondary outcomes, although the course was consistently slightly better. Adherence to the offered intervention was low. Health service utilization was not altered to a relevant extent. A subgroup analysis comparing adherent and non-adherent patients showed a consistently better course of adherent patients.

CONCLUSIONS

A risk-tailored short intervention to prevent chronic LBP in general practice had no significant impact on the clinical course compared to care as usual. A subgroup analysis comparing adherent and non-adherent patients suggests that it is possible to have a positive impact on patient-relevant outcomes.

The Fear-Avoidance Components Scale (FACS): Responsiveness to Functional Restoration Treatment in a Chronic Musculoskeletal Pain Disorder (CMPD) Population

OBJECTIVES

To assess the clinical validity and factor structure of the Fear-Avoidance Components Scale (FACS), a new fear-avoidance measure.

MATERIALS AND METHODS

In this study, 426 chronic musculoskeletal pain disorder patients were admitted to a Functional Restoration Program (FRP). They were categorized into 5 FACS severity levels, from subclinical to extreme, at admission, and again at discharge. Associations with objective lifting performance and other patient-reported psychosocial measures were determined at admission and discharge, and objective work outcomes for this predominantly disabled cohort, were assessed 1 year later.

RESULTS

Those patients in the severe and extreme FACS severity groups at admission were more likely to "drop out" of treatment than those in the lower severity groups (P=0.05). At both admission and discharge, the FACS severity groups were highly and inversely correlated with objective lifting performance and patient-reported fear-avoidance-related psychosocial variables, including kinesiophobia, pain intensity, depressive symptoms, perceived disability, perceived injustice, and insomnia (Ps<0.001). All variables showed improvement at FRP discharge. Patients in the extreme FACS severity group at discharge were less likely to return to, or retain, work 1 year later (P≤0.02). A factor analysis identified a 2-factor solution.

DISCUSSION

Strong associations were found among FACS scores and other patient-reported psychosocial and objective lifting performance variables at both admission and discharge. High discharge-FACS scores were associated with worse work outcomes 1 year after discharge. The FACS seems to be a valid and clinically useful measure for predicting attendance, physical performance, distress, and relevant work outcomes in FRP treatment of chronic musculoskeletal pain disorder patients.

Intensive spa and exercise therapy program for returning to work for low back pain patients: a randomized controlled trial

We aimed to determine whether a 5-day intensive inpatient spa and exercise therapy and educational program is more effective than usual care in improving the rate of returning to work at 1 year for patients with subacute and chronic low back pain (LBP) on sick leave for 4 to 24 weeks. We conducted a 12-month randomized controlled trial. LBP patients were assigned to 5-day spa (2 hr/day), exercise (30 min/day) and education (45 min/day) or to usual care. The primary outcome was the percentage of patients returning to work at 1 year after randomization. Secondary outcomes were pain, disability and health-related quality of life at 1 year and number of sick leave days from 6 to 12 months. The projected recruitment was not achieved. Only 88/700 (12.6%) patients planned were enrolled: 45 in the spa therapy group and 43 in the usual care group. At 1 year, returning to work was 56.3% versus 41.9% (OR 1.69 [95% CI 0.60-4.73], p = 0.32) respectively. There was no significant difference for any of the secondary outcomes. However, our study lacked power.

Knowledge, attitudes and beliefs on contributing factors among low back pain patients attending outpatient physiotherapy treatment in Malawi

BACKGROUND

Low back pain (LBP) affects many people globally. Its aetiology is not clear. Patients lack knowledge of its contributing factors and have negative perception about their LBP. This study aimed to identify knowledge, attitudes and beliefs regarding the perceived contributing factors to LBP among patients attending physiotherapy outpatient departments in Malawi. This information can possibly facilitate planning of a LBP education programme in Malawi.

METHODS

A quantitative cross-sectional survey was conducted, using a six-part self-administered questionnaire with questions on demographic information, participants' attitudes and beliefs regarding their LBP, knowledge about the course and causes of LBP, beliefs regarding nine contributing factors to LBP (identified in a Delphi study) and the sources of the participants' knowledge. Data were analysed descriptively using the Statistical Package for Social Sciences (version 19.0). A Chi-square test was used to determine any association between variables (alpha 0.05). All ethical procedures were strictly followed.

RESULTS

Most participants (186, 91.2 %) did not manage to answer all six questions regarding knowledge correctly and were regarded as 'partially knowledgeable' about the course and causes of LBP. More than half (67%) portrayed negative attitudes and beliefs about LBP in general. The findings also showed a statistically significant relationship between knowledge, attitudes and beliefs (p = 0.04).

CONCLUSION

This study highlighted that many patients with LBP in Malawi are not adequately knowledgeable about LBP and hold negative attitudes and beliefs regarding their LBP. Therefore, LBP management programmes in Malawi should include education programmes aimed at empowering patients with knowledge regarding LBP, as well as changing their negative attitudes and beliefs about their pain. Patients' understanding of the cause and nature of their pain may enhance the achievement of treatment goals.

A randomized controlled trial on the long-term effects of proprioceptive neuromuscular facilitation training, on pain-related outcomes and back muscle activity, in patients with chronic low back pain

BACKGROUND

The role of exercise therapy in improving pain-related clinical outcomes and trunk muscle activity in patients with chronic low back pain (CLBP) has been widely reported. There is little information on the effect of proprioceptive neuromuscular facilitation (PNF) training in patients with CLBP. The purpose of the present study was therefore to investigate the persistence of the effects of PNF training on pain intensity, functional disability, patient satisfaction, health-related quality of life (HRQOL) and lower back muscle activity in patients with CLBP.

METHODS

Forty-two participants with CLBP were randomly assigned either to 4-week PNF training or to a control group receiving a Low back pain educational booklet. Pain-related outcomes, including pain intensity, functional disability, patient satisfaction, HRQOL and lumbar erector spinae (LES) muscle activity, were measured before and after the intervention, and at a follow-up session 12 weeks after the last intervention session.

RESULTS

Compared with the control group, after undergoing a 4-week PNF training intervention, participants showed a significant reduction in pain intensity and functional disability, and improved patient satisfaction and HRQOL (p < 0.01). These effects were still significant at the 12-week follow-up assessment (p < 0.01). LES muscle activity in the PNF training group was significantly increased throughout the measurement periods compared with controls (p < 0.01).

CONCLUSIONS

The study found that 4-week PNF training has positive long-term effects on pain-related outcomes, and increases lower back muscle activity in patients with CLBP.

How best to use and evaluate Patient Information Leaflets given during a consultation: a systematic review of literature reviews

BACKGROUND

In the past, several authors have attempted to review randomized clinical trials (RCT) evaluating the impact of Patient Information Leaflets (PILs) used during a consultation and draw some general conclusions. However, this proved difficult because the clinical situations, size and quality of RCTs were too heterogeneous to pool relevant data.

OBJECTIVE

To overcome this 30-year stalemate, we performed a review of reviews and propose general recommendations and suggestions for improving the quality of PILs, how to use them and methods for evaluating them.

METHODOLOGY

We searched five databases for reviews, systematic reviews and meta-analyses describing PILs. We drew general and condition-linked conclusions concerning the impact of PILs. Checklists summarize criteria for quality PILs, and ways of using and evaluating them.

RESULTS

Of 986 articles found, 24 reviews were pertinent; the five oldest considered the impact of PILs irrespective of the condition the patient consulted for; the 19 more recent ones mostly addressed precise clinical situations.

DISCUSSION

Whatever the clinical situation, PILs improve patients' knowledge and satisfaction. For acute conditions, in the short-term PILs also improve adherence to treatment. For chronic diseases, invasive procedures or screening situations, their impact on adherence varies depending on the context, how the PILs are given and the invasiveness of the intervention.

CONCLUSION

PILs are considered to be very useful, especially for acute conditions where the patient is the first to suffer from lack of information. We propose checklists for writing, designing, using and evaluating PILs in RCTs to enable comparisons between different studies.

Can group-based reassuring information alter low back pain behavior? A cluster-randomized controlled trial

BACKGROUND

Low back pain (LBP) is common in the population and multifactorial in nature, often involving negative consequences. Reassuring information to improve coping is recommended for reducing the negative consequences of LBP. Adding a simple non-threatening explanation for the pain (temporary muscular dysfunction) has been successful at altering beliefs and behavior when delivered with other intervention elements. This study investigates the isolated effect of this specific information on future occupational behavior outcomes when delivered to the workforce.

DESIGN

A cluster-randomized controlled trial.

METHODS

Publically employed workers (n = 505) from 11 Danish municipality centers were randomized at center-level (cluster) to either intervention (two 1-hour group-based talks at the workplace) or control. The talks provided reassuring information together with a simple non-threatening explanation for LBP-the 'functional-disturbance'-model. Data collections took place monthly over a 1-year period using text message tracking (SMS). Primary outcomes were self-reported days of cutting down usual activities and work participation. Secondary outcomes were self-reported back beliefs, work ability, number of healthcare visits, bothersomeness, restricted activity, use of pain medication, and sadness/depression.

RESULTS

There was no between-group difference in the development of LBP during follow-up. Cumulative logistic regression analyses showed no between-group difference on days of cutting down activities, but increased odds for more days of work participation in the intervention group (OR = 1.83 95% CI: 1.08-3.12). Furthermore, the intervention group was more likely to report: higher work ability, reduced visits to healthcare professionals, lower bothersomeness, lower levels of sadness/depression, and positive back beliefs.

CONCLUSION

Reassuring information involving a simple non-threatening explanation for LBP significantly increased the odds for days of work participation and higher work ability among workers who went on to experience LBP during the 12-month follow-up. Our results confirm the potential for public-health education for LBP, and add to the discussion of simple versus multidisciplinary interventions.

Negative beliefs about low back pain are associated with persistent high intensity low back pain

While previous cross-sectional studies have found that negative beliefs about low back pain are associated with pain intensity, the relationship between back beliefs and persistent low back pain is not well understood. This cohort study aimed to examine the role of back beliefs in persistent low back pain in community-based individuals. A hundred and ninety-two participants from a previous musculoskeletal health study were invited to take part in a two-year follow-up study. Beliefs about back pain were assessed by the Back Beliefs Questionnaire (BBQ) at baseline and low back pain intensity was measured by the Chronic Pain Grade Questionnaire at baseline and follow-up. Of the 150 respondents (78.1%), 16 (10.7%) reported persistent high intensity low back pain, 12 (8.0%) developed high intensity low back pain, in 16 (10.7%) their high intensity low back pain resolved and 106 (70.7%) experienced no high intensity low back pain. While participants were generally positive about low back pain (BBQ mean (SD) = 30.2 (6.4)), those with persistent high intensity pain reported greater negativity (BBQ mean (SD) = 22.6 (4.9)). Negative beliefs about back pain were associated with persistent high intensity low back pain after adjusting for confounders (M (SE) = 23.5 (1.6) vs. >30.1 (1.7), p < .001). This study found negative back beliefs were associated with persistent high intensity low back pain over 2 years in community-based individuals. While further longitudinal studies are required, these findings suggest that targeting beliefs in programs designed to treat and prevent persistent high intensity low back pain may be important.

Cost-effectiveness of providing patients with information on managing mild low-back symptoms in an occupational health setting

BACKGROUND

Evidence shows that low back specific patient information is effective in sub-acute low back pain (LBP), but effectiveness and cost-effectiveness (CE) of information in early phase symptoms is not clear. We assessed effectiveness and CE of patient information in mild LBP in the occupational health (OH) setting in a quasi-experimental study.

METHODS

A cohort of employees (N = 312, aged <57) with non-specific, mild LBP (Visual Analogue Scale between 10-34 mm) was selected from the respondents of an employee survey (N = 2480; response rate 71 %). A random sample, representing the natural course of LBP (NC, N = 83; no intervention), was extracted as a control group. Remaining employees were invited (181 included, 47 declined, one excluded) into a randomised controlled study with two 1:1 allocated parallel intervention arms ("Booklet", N = 92; "Combined", N = 89). All participants received the "Back Book" patient information booklet and the Combined also an individual verbal review of the booklet. Physical impairment (PHI), LBP, health care (HC) utilisation, and all-cause sickness absence (SA) were assessed at two years. CE of the interventions on SA days was analysed by using direct HC costs in one year, two years from baseline. Multiple imputation was used for missing values.

RESULTS

Compared to NC, the Booklet reduced HC costs by 196€ and SA by 3.5 days per year. In 81 % of the bootstrapped cases the Booklet was both cost saving and effective on SA. Compared to NC, in the Combined arm, the figures were 107€, 0.4 days, and 54 %, respectively. PHI decreased in both interventions.

CONCLUSIONS

Booklet information alone was cost-effective in comparison to natural course of mild LBP. Combined information reduced HC costs. Both interventions reduced physical impairment. Mere booklet information is beneficial for employees who report mild LBP in the OH setting, and is also cost saving for the health care system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00908102.

[Non-randomised trial of an educational intervention based on cognitive-behavioural principles for patients with chronic low back pain attended in Primary Care Physiotherapy]

Objetivo

Valorar la influencia de una intervención educativa en la reducción del «miedo-evitación» (ME) y del «catastrofismo al dolor» (CAT) en población con lumbalgia crónica inespecífica (LCI) atendida en fisioterapia de atención primaria (AP).

Diseño

Estudio cuasiexperimental.

Emplazamiento

Centros de salud (CS) del Distrito Sanitario Costa del Sol.

Participantes

Pacientes con LCI entre 18-65 años con comprensión del idioma español; ausencia de intervenciones educativas paralelas; ausencia de banderas rojas; ausencia de deterioro cognitivo y/o fibromialgia; ausencia de cirugía dorsolumbar, y tolerancia al ejercicio físico.

Intervenciones

El grupo control recibió la EdE grupal habitual. El experimental recibió, además, un instrumento escrito para lectura domiciliaria, más la posterior puesta en común, aclaración de dudas y reestructuración de creencias y metas durante el desarrollo de las sesiones. Ambas intervenciones duraron unos 280 min (7 sesiones de 40 min).

Resultados

Las variables principales incluyeron ME y CAT. Secundariamente se valoraron dolor y discapacidad. Algunas variables «sociodemográficas» y «relacionadas con el trastorno» fueron tenidas en cuenta en el análisis.

Se observaron diferencias estadísticamente significativas en el grupo experimental versus control en la variación del ME −14 (−25,5; 0) vs −4 (−13; 0) (p = 0,009), y del CAT −9 (−18; −4) vs −4,5 (−8,25; 0) (p = 0,000). Igualmente se observaron diferencias en discapacidad (p = 0,046), pero no en dolor (p = 0,280).

Conclusiones

Los resultados deben ser considerados a la luz de las posibles limitaciones que plantea el estudio. Su naturaleza pragmática permitiría una potencial transferencia a la dinámica asistencial habitual.

Fear and difficulty perceived when visualizing therapeutic exercise in patients with chronic low back pain: A cross-sectional study

The main aim of this study was to evaluate the perceived level of difficulty and fear of movement among patients with chronic low back pain (CLBP) compared with asymptomatic subjects when they visualized motor control therapeutic exercises (MCTEs) commonly used in physiotherapy. Our secondary objective was to analyse the correlation between fear of MCTEs and other psychological and disability variables. Thirty patients with CLBP comprised the treatment group, and 30 asymptomatic subjects comprised the control group. The procedure consisted of showing photographs and videos of seven MCTEs and having the participants rate their perceived difficulty and fear. Participants then answered a series of psychological self-report measures. Differences were found between groups in perceived difficulty of the MCTEs shown in videos (F=21.06, P<0.001) and photographs (F=15.86, P<0.001), as well as for perceived fear (F=9.71, P<0.001; F=8.61, P<0.001, respectively). Regression analysis indicated that in the CLBP group the predictor variable for perceived difficulty and fear was the lumbar disability (explaining 44% and 28% of the variance, respectively), however in the control group the predictor variables were catastrophizing and self-efficacy (38% and 34% of the variance, respectively). In conclusion, patients with CLBP experience greater perceived level of difficulty and fear of movement when visualizing MCTEs than asymptomatic subjects. Psychological factors and disability were correlated with perceived difficulty and fear when videos and photographs of exercises were shown.

Interventions focusing on psychosocial risk factors for patients with non-chronic low back pain in primary care--a systematic review

BACKGROUND

Low back pain (LBP) is a problem that is frequently encountered in primary care, and current guidelines encourage care providers to take into account psychosocial risk factors in order to avoid transition from acute to chronic LBP.

OBJECTIVE

To review the effectiveness of interventions focusing on psychosocial risk factors for patients with non-chronic LBP in primary care.

METHODS

A systematic search was undertaken for controlled trials focusing on psychosocial factors in adult patients with non-chronic, non-specific LBP in primary care by exploring Medline, Embase, PsycInfo, Francis, Web of Sciences and The Cochrane Library. The methodological quality of the studies included was assessed before analysing their findings.

RESULTS

Thirteen studies were selected, seven being considered as having a low risk of bias. Information strategies were assessed by eight trials, with high-quality evidence of no effectiveness for pain, function, work issues and health care use, low-quality evidence of no effectiveness for self-rated overall improvement, satisfaction and pain beliefs and lack of evidence in terms of quality of life. Cognitive behavioural therapy was assessed by three trials, with very low-quality evidence of moderate effectiveness for pain, function, quality of life, work issues and health care use. There was lack of evidence concerning the effectiveness of individual and group education intervention or work coordination.

CONCLUSION

Among the wide range of psychosocial risk factors, research has focused mainly on pain beliefs and coping skills, with disappointing results. Extended theoretical models integrating several psychosocial factors and multicomponent interventions are probably required to meet the challenge of LBP.

Translating evidence for low back pain management into a consumer-focussed resource for use in community pharmacies: a cluster-randomised controlled trial

Background

This cluster-randomised controlled trial determined the effectiveness of an evidence-based, pamphlet intervention in improving low back pain (LBP)-related beliefs among pharmacy consumers.

Methods

Thirty five community pharmacies were randomised to three groups: pamphlet+education intervention [n = 11]; pamphlet only intervention [n = 11]; control: usual care [n = 13]. Eligibility requirements for clusters included: community-based pharmacies and proprietor participation consent. Pharmacy consumers (N = 317) aged 18–65 years currently experiencing LBP participated. Intervention group allocation depended on the pharmacy attended. Individual-level outcomes were measured at pre-intervention (T0), at two (T1) and eight (T2) weeks post-intervention and included beliefs about LBP [Back Pain Beliefs Questionnaire (BBQ); Fear Avoidance Beliefs Questionnaire (FABQ)]. Secondary outcomes included pain severity, activity impairment and pamphlet perceived usefulness. Blinding to group allocation included primary investigators, outcome assessors and the statistician. Pharmacy staff and consumers were un-blinded.

Results

Of 35 pharmacies recruited (317 consumers), no clusters were lost to follow-up. Follow-up was available for n = 24 at 2 weeks only; n = 38 at 8 weeks only; n = 148 at both time points, with n = 148+24+38 = 210 analysed (107 excluded: no follow up). Adjusting for baseline scores demonstrated no significant differences in beliefs (2 or at 8 weeks) between pamphlet (with or without education) versus control, or between ‘pamphlet with’ versus ‘without’ education. Work-related fear (FABQ) was significantly lower in consumers receiving pamphlet (with or without education) versus control (difference −2.3, 95%CI: −4.4 to −0.2). There was no significant difference between “pamphlet with” versus “pamphlet without” groups. Consumers receiving the “pamphlet with” reported greater perceived usefulness than consumers receiving the “pamphlet without” (difference 0.9 (95%CI: 0.0 to 1.8)).

Conclusion

Community pharmacies provided a feasible primary care portal for implementing evidence-based information. The associated improvement in work-related LBP-beliefs for consumers receiving the pamphlet suggests this simple intervention may be a useful component of care.

Trial Registration

ACTR.org.au ACTRN12611000053921

The effects of quality of care on costs: a conceptual framework

CONTEXT

The quality of health care and the financial costs affected by receiving care represent two fundamental dimensions for judging health care performance. No existing conceptual framework appears to have described how quality influences costs.

METHODS

We developed the Quality-Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources.

FINDINGS

The Quality-Cost Framework describes how health-related quality of care (aspects of quality that influence health status) affects health care and other costs. Structure influences process, which, in turn, affects proximate and ultimate outcomes. Within structure, subdomains include general structural characteristics, circumstance-specific (e.g., disease-specific) structural characteristics, and quality-improvement systems. Process subdomains include appropriateness of care and medical errors. Proximate outcomes consist of disease progression, disease complications, and care complications. Each of the preceding subdomains influences health care costs. For example, quality improvement systems often create costs associated with monitoring and feedback. Providing appropriate care frequently requires additional physician visits and medications. Care complications may result in costly hospitalizations or procedures. Ultimate outcomes include functional status as well as length and quality of life; the economic value of these outcomes can be measured in terms of health utility or health-status-related costs. We illustrate our framework using examples related to glycemic control for type 2 diabetes mellitus or the appropriateness of care for low back pain.

CONCLUSIONS

The Quality-Cost Framework describes the mechanisms by which health-related quality of care affects health care and health status-related costs. Additional work will need to validate the framework by applying it to multiple clinical conditions. Applicability could be assessed by using the framework to classify the measures of quality and cost reported in published studies. Usefulness could be demonstrated by employing the framework to identify design flaws in published cost analyses, such as omitting the costs attributable to a relevant subdomain of quality.

Management options for patients with chronic back pain without an etiology

The treatment and management of low back pain is complex when there is no specific etiology such as cancer, fracture, or herniated disc. An organized approach to management that follows evidence based guidelines will facilitate care in a problem that reflects a lifetime prevalence of over 70 percent. The purpose of this review is to present a guideline to care for a common disabling process with a very heterogeneous etiology.

The PRESLO study: evaluation of a global secondary low back pain prevention program for health care personnel in a hospital setting. Multicenter, randomized intervention trial

Background

Common low back pain represents a major public health problem in terms of its direct cost to health care and its socio-economic repercussions. Ten percent of individuals who suffer from low back pain evolve toward a chronic case and as such are responsible for 75 to 80% of the direct cost of low back pain. It is therefore imperative to highlight the predictive factors of low back pain chronification in order to lighten the economic burden of low back pain-related invalidity. Despite being particularly affected by low back pain, Hospices Civils de Lyon (HCL) personnel have never been offered a specific, tailor-made treatment plan. The PRESLO study (with PRESLO referring to Secondary Low Back Pain Prevention, or in French, PREvention Secondaire de la LOmbalgie), proposed by HCL occupational health services and the Centre Médico-Chirurgical et de Réadaptation des Massues – Croix Rouge Française, is a randomized trial that aims to evaluate the feasibility and efficiency of a global secondary low back pain prevention program for the low back pain sufferers among HCL hospital personnel, a population at risk for recurrence and chronification. This program, which is based on the concept of physical retraining, employs a multidisciplinary approach uniting physical activity, cognitive education about low back pain and lumbopelvic morphotype analysis. No study targeting populations at risk for low back pain chronification has as yet evaluated the efficiency of lighter secondary prevention programs.

Methods/Design

This study is a two-arm parallel randomized controlled trial proposed to all low back pain sufferers among HCL workers, included between October 2008 and July 2011 and followed over two years. The personnel following their usual treatment (control group) and those following the global prevention program in addition to their usual treatment (intervention group) are compared in terms of low back pain recurrence and the impairments measured at the beginning and the end of the study. The global prevention program is composed of a two-hour information session about low back pain and pain pathways, followed by five weekly 90-min exercise sessions with one physiotherapist per group of eight to ten personnel. A booklet for home use with patient-managed exercise instructions and information (The Back Book) is given to each participant at the end of the program.

An X-ray assessment of the entire spinal column of each participant (in both the control and intervention groups) is performed at the onset of the study in order to analyze sagittal spinopelvic balance as well as lombopelvic morphotype.

Discussion

The results of this study, which is innovative and unique in France, will be available in 2014 and will make it possible to draw conclusions regarding the program’s impact on the risk of recurrence and chronification of low back pain.

Trial registration

http://www.clinicaltrials.gov # NCT00782925

Fostering change in back pain beliefs and behaviors: when public education is not enough

Mass media campaigns designed to alter societal views and individual behaviors about back pain have been undertaken and evaluated in multiple countries. In contrast to the original Australian campaign, subsequent campaigns have been less successful, with improvements observed in beliefs without the corresponding changes in related behaviors. This article summarizes the results of a literature review, expert panel, and workshop held at the Melbourne International Forum XI: Primary Care Research on Low Back Pain in March 2011 on the role and interplay of various social behavior change strategies, including public education, law and legislation, healthy public policy, and social marketing in achieving a sustained reduction in the societal burden of back pain. Given the complexities inherent to health-related behaviors change, the Rothschild framework is applied in which behavior change strategies are viewed on a continuum from public education at one end through law and health policy at the other. Educational endeavors should likely be augmented with social marketing endeavors and supportive laws and health policy to foster sustained change in outcomes such as work disability and health utilization. Practical suggestions are provided for future interventions aimed at changing back pain-related behaviors. Evaluation of previous back pain mass media campaigns reveals that education alone is unlikely to foster positive and persisting behavioral change without concomitant strategies.

Low back pain

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.

Evaluation of the benefits of low back pain patients' education workshops during spa therapy

OBJECTIVES

To evaluate the medium-term impact of education workshops on low back pain (LBP) in the setting of a thermal spa on: fear-avoidance beliefs, disability, pain, and satisfaction.

METHODS

Randomized prospective alternate-month design-type study including 360 individuals having thermal spa therapy for LBP: 188 in the intervention group (three standardized education workshops lasting 1 h 30 each and usual thermal therapy for 3 weeks), 172 in the control group (usual thermal therapy and non-standardized verbal information). The principal analysis criterion was the difference in the fear-avoidance beliefs (physical FABQ) score between baseline and 6 months after the therapy; secondary criteria were: evolution of disability (Quebec Scale) and pain intensity (Visual Analogue Scale), and satisfaction with the information received.

RESULTS

There was a significant reduction in the physical FABQ score at 6 months (P<0.05), and this reduction was more marked in the intervention group (-5.8±0.7 vs. -2±0.72 points out of 24; P<0.0001). Disability and pain significantly decreased in both groups (P<0.05), with no difference between groups. These workshops also had a significant effect on satisfaction with the information received.

CONCLUSION

Standardized education workshops have a beneficial impact on LBP and contribute to an improvement in the medical services provided during spa therapy by reducing the effect of fear-avoidance beliefs as well as relieving pain. Extending the use of such workshops could contribute to enhance the positive impact of spa therapy in the management of chronic disabling diseases.

Predictors of occurrence and severity of first time low back pain episodes: findings from a military inception cohort

Primary prevention studies suggest that additional research on identifying risk factors predictive of low back pain (LBP) is necessary before additional interventions can be developed. In the current study we assembled a large military cohort that was initially free of LBP and followed over 2 years. The purposes of this study were to identify baseline variables from demographic, socioeconomic, general health, and psychological domains that were predictive of a) occurrence; b) time; and c) severity for first episode of self-reported LBP. Baseline and outcome measures were collected via web-based surveillance system or phone to capture monthly information over 2 years. The assembled cohort consisted of 1230 Soldiers who provided self-report data with 518 (42.1%) reporting at least one episode of LBP over 2 years. Multivariate logistic regression analysis indicated that gender, active duty status, mental and physical health scores were significant predictors of LBP. Cox regression revealed that the time to first episode of LBP was significantly shorter for Soldiers that were female, active duty, reported previous injury, and had increased BMI. Multivariate linear regression analysis investigated severity of the first episode by identifying baseline predictors of pain intensity, disability, and psychological distress. Education level and physical fitness were consistent predictors of pain intensity, while gender, smoking status, and previous injury status were predictors of disability. Gender, smoking status, physical health scores, and beliefs of back pain were consistent predictors of psychological distress. These results provide additional data to confirm the multi-factorial nature of LBP and suggest future preventative interventions focus on multi-modal approaches that target modifiable risk factors specific to the population of interest.

Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial

BACKGROUND

Effective strategies for the primary prevention of low back pain (LBP) remain elusive with few large-scale clinical trials investigating exercise and education approaches. The purpose of this trial was to determine whether core stabilization alone or in combination with psychosocial education prevented incidence of low back pain in comparison to traditional lumbar exercise.

METHODS

The Prevention of Low Back Pain in the Military study was a cluster randomized clinical study with four intervention arms and a two-year follow-up. Participants were recruited from a military training setting from 2007 to 2008. Soldiers in 20 consecutive companies were considered for eligibility (n = 7,616). Of those, 1,741 were ineligible and 1,550 were eligible but refused participation. For the 4,325 Soldiers enrolled with no previous history of LBP average age was 22.0 years (SD = 4.2) and there were 3,082 males (71.3%). Companies were randomly assigned to receive traditional lumbar exercise, traditional lumbar exercise with psychosocial education, core stabilization exercise, or core stabilization with psychosocial education, The psychosocial education session occurred during one session and the exercise programs were done daily for 5 minutes over 12 weeks. The primary outcome for this trial was incidence of low back pain resulting in the seeking of health care.

RESULTS

There were no adverse events reported. Evaluable patient analysis (4,147/4,325 provided data) indicated no differences in low back incidence resulting in the seeking of health care between those receiving the traditional exercise and core stabilization exercise programs. However, brief psychosocial education prevented low back pain episodes regardless of the assigned exercise approach, resulting in a 3.3% (95% CI: 1.1 to 5.5%) decrease over two years (numbers needed to treat (NNT) = 30.3, 95% CI = 18.2 to 90.9).

CONCLUSIONS

Core stabilization has been advocated as preventative, but offered no such benefit when compared to traditional lumbar exercise in this trial. Instead, a brief psychosocial education program that reduced fear and threat of low back pain decreased incidence of low back pain resulting in the seeking of health care. Since this trial was conducted in a military setting, future studies are necessary to determine if these findings can be translated into civilian populations.

TRIAL REGISTRATION

NCT00373009 at ClinicalTrials.gov - http://clinicaltrials.gov/

A psychometric investigation of fear-avoidance model measures in patients with chronic low back pain

STUDY DESIGN

Validity and test-retest reliability of questionnaires related to the fear-avoidance model (FAM).

OBJECTIVE

To investigate test-retest reliability, construct redundancy, and criterion validity for 4 commonly used FAM measures.

BACKGROUND

Few studies have reported psychometric properties for more than 2 FAM measures within the same cohort, making it difficult to determine which specific measures should be implemented in outpatient physical therapy settings.

METHODS

Fifty-three consecutive patients (mean age, 44.3 + or - 18.5 years) with chronic low back pain participated in this study. Data were collected with validated measures for FAM constructs, including the Fear-Avoidance Beliefs Questionnaire (FABQ), Fear of Pain Questionnaire (FPQ), Tampa Scale for Kinesiophobia, and Pain Catastrophizing Scale. Validated measures were used to investigate criterion validity of the FAM measures, including the Patient Health Questionnaire for depression, the numerical rating scale for pain intensity, the Physical Impairment Scale for physical impairment, and the Oswestry Disability Questionnaire for self-report of disability. Test-retest reliability of the FAM measures was determined with intraclass correlation coefficients (ICC2,1) for total questionnaire scores at baseline and 48 hours later. Construct redundancy was determined with Pearson correlation coefficients for FAM measures. Criterion validity was assessed by 4 separate multiple regression models that included age, sex, and employment status as covariates. Depression, pain intensity, physical impairment, and disability were the dependent variables for these analyses.

RESULTS

Test-retest ICC coefficients ranged from 0.90 to 0.96 for all FAM questionnaires. The FAM measures were significantly correlated with each other, with the only exception being that the FPQ was not correlated with the FABQ work scale. In the multiple regression models, the Pain Catastrophizing Scale contributed additional variance to depression. The FABQ physical activity scale contributed additional variance to pain intensity and disability. The FABQ work scale contributed additional variance to physical impairment and disability. No other FAM measures contributed to these regression models.

CONCLUSION

These data suggest that 4 commonly used FAM measures have similar test-retest reliability, with varying amounts of construct redundancy. The criterion validity analyses suggest that measurement of fear-avoidance constructs for patients seeking outpatient physical therapy with chronic low back pain should include the Pain Catastrophizing Scale and the FABQ.

The Hip and Knee Book: developing an active management booklet for hip and knee osteoarthritis

BACKGROUND

The pain and disability of hip and knee osteoarthritis can be improved by exercise, but the best method of encouraging this is not known.

AIM

To develop an evidence-based booklet for patients with hip or knee osteoarthritis, offering information and advice on maintaining activity.

DESIGN OF STUDY

Systematic review of reviews and guidelines, then focus groups.

SETTING

Four general practices in North East Wales.

METHOD

Evidence-based messages were developed from a systematic review, synthesised into patient-centred messages, and then incorporated into a narrative. A draft booklet was examined by three focus groups to improve the phrasing of its messages and discuss its usefulness. The final draft was examined in a fourth focus group.

RESULTS

Six evidence-based guidelines and 54 systematic reviews were identified. The focus groups found the draft booklet to be informative and easy to read. They reported a lack of clarity about the cause of osteoarthritis and were surprised that the pain could improve. The value of exercise and weight loss beliefs was accepted and reinforced, but there was a perceived contradiction about heavy physical work being causative, while moderate exercise was beneficial. There was a fear of dependency on analgesia and misinterpretation of the message on hyaluranon injections. The information on joint replacement empowered patients to discuss referral with their GP. The text was revised to accommodate these issues.

CONCLUSION

The booklet was readable, credible, and useful to end-users. A randomised controlled trial is planned, to test whether the booklet influences beliefs about osteoarthritis and exercise.

Development of a self-report measure of fearful activities for patients with low back pain: the fear of daily activities questionnaire

BACKGROUND

Self-report measures for assessing specific fear of activities have not been reported in the peer-reviewed literature, but are necessary to adequately test treatment hypotheses related to fear-avoidance models.

OBJECTIVE

This study described psychomotor properties of a novel self-report measure, the Fear of Daily Activities Questionnaire (FDAQ).

DESIGN

A prospective cohort design was used.

METHODS

Reliability and validity cohorts were recruited from outpatient physical therapy clinics. Analyses for the reliability cohort included internal consistency and 48-hour test-retest coefficients, as well as standard error of measurement and minimal detectable change estimates. Analyses for the validity cohort included factor analysis for construct validity and correlation and multiple regression analyses for concurrent and predictive validity. Four-week responsiveness was assessed by paired t test, effect size calculation, and percentage of patients meeting or achieving MDC criterion.

RESULTS

The FDAQ demonstrated adequate internal consistency (Cronbach alpha=.91, 95% confidence interval=.87-.95) and 48-hour test-retest properties (intraclass correlation coefficient=.90, 95% confidence interval=.82-.94). The standard error of measurement for the FDAQ was 6.6, resulting in a minimal detectable change of 12.9. Factor analysis suggested a 2- or 3-factor solution consisting of loaded spine, postural, and spinal movement factors. The FDAQ demonstrated concurrent validity by contributing variance to disability (baseline and 4 weeks) and physical impairment (baseline) scores. In predictive validity analyses, baseline FDAQ scores did not contribute variance to 4-week disability and physical impairment scores, but changes in FDAQ scores were associated with changes in disability. The FDAQ scores significantly decreased over a 4-week treatment period, with an effect size of .86 and 55% of participants meeting the minimal detectable change criterion.

LIMITATIONS

The validity cohort was a secondary analysis of a clinical trial, and additional research is needed to confirm these findings in other samples.

CONCLUSIONS

The FDAQ is a potentially viable measure for fear of specific activities in physical therapy settings. These analyses suggest the FDAQ may be appropriate for determining graded exposure treatment plans and monitoring changes in fear levels, but is not appropriate as a screening tool.

The Back Disability Risk Questionnaire for work-related, acute back pain: prediction of unresolved problems at 3-month follow-up

OBJECTIVE

To assess the validity of the Back Disability Risk Questionnaire (BDRQ) to predict developing chronic back disability.

METHODS

Five hundred nineteen working adults (67% male) seeking outpatient care for acute, work-related back pain (<or=14 days) completed the BDRQ. After the initial medical evaluation, clinicians provided prognostic impressions in a 10-item questionnaire. Pain, functional limitation, and work status were assessed at 3-month follow-up.

RESULTS

In multivariate analyses, the presence of persistent pain, functional limitation, or impaired work status (31.4%) was predicted by six BDRQ questions: injury type, work absence preceding medical evaluation, job tenure, prior back surgery, worries about re-injury, expectation for early return-to-work, and stress. Classification accuracy at 3 months was 76.3%. Initial clinician impressions showed no multivariate associations with outcomes.

CONCLUSIONS

The BDRQ may provide prognostic information not observed in a routine medical evaluation for acute BP.

Psychosocial education improves low back pain beliefs: results from a cluster randomized clinical trial (NCT00373009) in a primary prevention setting

The general population has a pessimistic view of low back pain (LBP), and evidence-based information has been used to positively influence LBP beliefs in previously reported mass media studies. However, there is a lack of randomized trials investigating whether LBP beliefs can be modified in primary prevention settings. This cluster randomized clinical trial investigated the effect of an evidence-based psychosocial educational program (PSEP) on LBP beliefs for soldiers completing military training. A military setting was selected for this clinical trial, because LBP is a common cause of soldier disability. Companies of soldiers (n = 3,792) were recruited, and cluster randomized to receive a PSEP or no education (control group, CG). The PSEP consisted of an interactive seminar, and soldiers were issued the Back Book for reference material. The primary outcome measure was the back beliefs questionnaire (BBQ), which assesses inevitable consequences of and ability to cope with LBP. The BBQ was administered before randomization and 12 weeks later. A linear mixed model was fitted for the BBQ at the 12-week follow-up, and a generalized linear mixed model was fitted for the dichotomous outcomes on BBQ change of greater than two points. Sensitivity analyses were performed to account for drop out. BBQ scores (potential range: 9-45) improved significantly from baseline of 25.6 +/- 5.7 (mean +/- SD) to 26.9 +/- 6.2 for those receiving the PSEP, while there was a significant decline from 26.1 +/- 5.7 to 25.6 +/- 6.0 for those in the CG. The adjusted mean BBQ score at follow-up for those receiving the PSEP was 1.49 points higher than those in the CG (P < 0.0001). The adjusted odds ratio of BBQ improvement of greater than two points for those receiving the PSEP was 1.51 (95% CI = 1.22-1.86) times that of those in the CG. BBQ improvement was also mildly associated with race and college education. Sensitivity analyses suggested minimal influence of drop out. In conclusion, soldiers that received the PSEP had an improvement in their beliefs related to the inevitable consequences of and ability to cope with LBP. This is the first randomized trial to show positive influence on LBP beliefs in a primary prevention setting, and these findings have potentially important public health implications for prevention of LBP.

Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women

Background

Although previous studies have investigated beliefs about back pain in clinical and employed populations, there is a paucity of data examining the beliefs of the broader community. We aimed to characterize the beliefs that community-dwelling women have about back pain and its consequences, and to determine whether those with varying levels of pain intensity and disability differ in their beliefs.

Methods

542 community-dwelling women, aged 24 to 80 years, were recruited from a research database. Participants completed a self-administered questionnaire that included detailed demographic information, the Chronic Pain Grade Questionnaire (CPG) and the Back Beliefs Questionnaire (BBQ). The CPG examined individuals' levels of pain intensity and disability, and the BBQ investigated their beliefs about back pain and its consequences.

Results

506 (93.4%) women returned the study questionnaire. The mean (SD) BBQ score for the cohort was 30.7 (6.0), indicating generally positive beliefs about back pain. However, those women with high intensity pain and high level disability had a mean (SD) score of 28.5 (5.7) and 24.8 (5.7) respectively, which reflects greater negativity about back pain and its consequences. There was an association between negative beliefs and high pain intensity (OR = 0.94 (95% CI: 0.90, 0.99), p = 0.01) and high level disability (OR = 0.93 (95% CI: 0.89, 0.97), p = 0.001), after adjusting for confounders.

Conclusion

This study highlights that although women living in the community were generally positive about back pain, subgroups of women with high pain intensity and high level disability were identified who had more pessimistic views. While a causal relationship cannot be inferred from these cross-sectional data, the results suggest that negative beliefs individuals have about back pain may be predictive of chronic, disabling spinal pain.