Are Changes in Fear-Avoidance Beliefs and Self-efficacy Mediators of Function and Pain at Discharge in Patients With Acute and Chronic Low Back Pain?

Effectiveness of remotely delivered motivational conversations on health outcomes in patients living with musculoskeletal conditions: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of remotely delivered motivational conversations on health outcomes in musculoskeletal populations.

METHODS

Four electronic databases (inception-March 2022) were searched and combined with grey literature. Randomised control trials (RCTs) evaluating the effect of remotely delivered motivational conversation-based interventions within musculoskeletal populations, using valid measures of pain, disability, quality of life (QoL), or self-efficacy were included. Overall quality was assessed using GRADE criteria. Meta-analyses were performed using random effects models with pooled effect sizes expressed as standardised mean differences ( ± 95%CIs).

RESULTS

Twelve RCTs were included. Meta-analyses revealed very-low to moderate quality evidence that remote interventions have a positive effect on pain and disability both immediately post intervention and at long-term follow-up compared to control, and have a positive effect on self-efficacy immediately post intervention. There was no effect on QoL immediately post intervention or at long-term follow up.

CONCLUSION

Remotely delivered motivation-based conversational interventions have a positive effect on pain, disability, and self-efficacy but not on QoL.

PRACTICE IMPLICATIONS

Motivational conversations, delivered remotely, may be effective in improving some health-related outcomes in MSK populations. However, higher quality evidence is needed to determine optimal intervention durations, and dosing frequencies using sufficient sample sizes and follow-up time frames.

Understanding How Patients With Lumbar Radiculopathy Make Sense of and Cope With Their Symptoms

Lumbar radiculopathy, characterized by pain radiating along a nerve root, significantly diminishes the quality of life due to its neuropathic nature. Patients' understanding of their illness and the coping strategies they employ directly influence how they manage their condition. Understanding these illness representations from the patient's perspective is crucial for healthcare providers seeking to optimize treatment outcomes. This study adopted a qualitative interpretive/constructive paradigm to explore this dynamic. A qualitative evidence synthesis approach, utilizing best-fit framework synthesis for data extraction, was applied to analyze primary qualitative studies focused on patient experiences with lumbar radiculopathy. Using SPiDER (Sample, Phenomenon of interest, Design, Evaluation, Research type) to guide the search strategy, extracted data was mapped against the Common-Sense Model of Self-Regulation (CSM) framework. Sixteen studies, with moderate to minor methodological quality concerns, were included in the analysis. Data mapping across CSM domains generated 14 key review findings. Results suggest that patients with high-threat illness representations often exhibit maladaptive coping behaviors (e.g., activity avoidance) driven by emotional responses. In contrast, problem-solving techniques appear to contribute to positive outcomes (e.g., exercise adherence and effective self-management) in patients who perceive their condition as less threatening. These findings highlight the potential benefits of interventions designed to reduce perceived threat levels and enhance self-efficacy in patients with lumbar radiculopathy, leading to improved self-management and ultimately better health outcomes.

Similarities between explaining dizziness and explaining pain? Exploring common patient experiences, theoretical models, treatment approaches and potential therapeutic narratives for persistent dizziness or pain

Pain and dizziness are common experiences throughout the lifespan. However, nearly a quarter of those with acute pain or dizziness experience persistence, which is associated with disability, social isolation, psychological distress, decreased independence, and poorer quality of life. Thus, persistent pain or dizziness impacts peoples' lives in similarly negative ways. Conceptual models of pain and dizziness also have many similarities. Many of these models are more expansive than explaining mere symptoms; rather they describe pain or dizziness as holistic experiences that are influenced by biopsychosocial and contextual factors. These experiences also appear to be associated with multi-modal bodily responses related to evaluation of safety, threat detection and anticipation, as influenced by expectations, and predictions anticipation, not simply a reflection of tissue injury or pathology. Conceptual models also characterize the body as adaptable and therefore capable of recovery. These concepts may provide useful therapeutic narratives to facilitate understanding, dethreaten the experience, and provide hope for patients. In addition, therapeutic alliance, promoting an active movement-based approach, building self-efficacy, and condition-specific approaches can help optimize outcomes. In conclusion, there are significant overlaps in the patient experience, theoretical models and potential therapeutic narratives that guide care for people suffering with persistent pain or dizziness.

What are the benefits of cultivating self-compassion in adults with low back pain? A systematic review

Introduction

Low back pain is one of the most prevalent public health problems in the world, generating psychosocial impacts on quality of life and a high demand for medical care. Self-compassion may be beneficial for low back pain control, however, studies in the area are scarce. Therefore, this systematic review aimed to investigate the benefits of self-compassion-related interventions on low back pain and mental health in adults.

Methods

The review protocol was registered in PROSPERO and the method was performed according to the PRISMA guidelines. Searches were conducted using the keywords "self-compassion" and "low back pain" in Portuguese, English, and Spanish in the following databases: PubMed, LILACS, SciELO, PePSIC, PsycInfo, Embase, Scopus, Web of Science, and Cochrane. Additional searches were also conducted through the references of the included studies.

Results

Thirty-three articles were identified and analyzed by two independent reviewers using Rayyan. Four of these studies were included. RoB 2 was used to assess the risk of bias of each study. The main findings suggest that self-compassion-related interventions demonstrate benefits in the treatment of low back pain, as well as reduction in pain intensity, psychological stress, and improvement of pain acceptance.

Discussion

However, these positive data must be analyzed carefully, as only two studies presented a low risk of bias. Despite growing interest in this field, more research self-compassion-related interventions for low back pain are suggested, since biopsychosocial aspects associated with low back pain can impact the outcome of treatment.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier (CRD42022376341).

The relationships between pain-associated psychological distress, pain intensity, patient expectations, and physical function in individuals with musculoskeletal pain: A retrospective cohort study

INTRODUCTION

The presence of pain-associated psychological distress (PAPD) in musculoskeletal disorders, including negative mood, fear-avoidance, and lack of positive affect/coping, is associated with prolonged disability. The importance of considering psychological influence on pain is well known, but practical ways of addressing it are not as straightforward. Identifying relationships between PAPD and pain intensity, patient expectations, and physical function may guide the development of future studies that assess causality and inform clinical practice.

OBJECTIVE

To assess the relationship between PAPD measured by the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag tool, and baseline pain intensity, expectations of treatment effectiveness, and self-reported physical function at discharge.

DESIGN

Retrospective cohort study.

SETTING

Hospital-based outpatient physical therapy.

PARTICIPANTS

Patients 18 to 90 years old with spinal pain or lower extremity osteoarthritis.

MAIN OUTCOME MEASURES

Pain intensity and patient expectations of treatment effectiveness at intake, and self-reported physical function at discharge.

RESULTS

A total of 534 patients, 56.2% female, median (interquartile range [IQR]) age 61 (21) years with an episode of care between November 2019 and January 2021 were included. A multiple linear regression showed a significant association between PAPD and pain intensity with 6.4% (p < .001) of the variance explained. PAPD explained 3.3% (p < .001) of the variance in patient expectations. One additional yellow flag present resulted in a 0.17-point increase in pain intensity and 1.3% decrease in patient expectations. PAPD was also associated with physical function with 3.2% (p < .001) of the variance explained. PAPD explained 9.1% (p < .001) of the variance in physical function at discharge in the low back pain cohort only when assessed independently by body region.

CONCLUSION

These findings support the theory that the pain experience is complex and multiple factors should be considered when evaluating a patient with musculoskeletal pain. Clinicians who have identified PAPD may consider these relationships when planning or modifying interventions and pursuing multidisciplinary collaboration.

Effects of Virtual Reality Exercises on Chronic Low Back Pain: Quasi-Experimental Study

BACKGROUND

Low back pain is a common health problem globally. Based on the duration of pain, it is classified as acute, subacute, or chronic low back pain. Different treatment strategies are available to reduce chronic low back pain. Virtual reality (VR) is a novel approach in back pain rehabilitation.

OBJECTIVE

This study aimed to compare the effects of VR games on chronic low back pain.

METHODS

This quasi-experimental study was conducted among 40 patients with chronic low back pain. The data were collected using a nonprobability, convenient sampling technique. Patients visiting the Department of Physiotherapy, Government Services Hospital, Lahore, Pakistan, were recruited and equally divided into 4 groups. Group A received the Reflex Ridge game; group B received the Body Ball game; group C combined the 2 games without back-strengthening exercises; and group D combined the 2 games with back-strengthening exercises. The participants received 8 treatment sessions, with 3 sessions/wk. The outcomes were pre- and posttest measurements of pain intensity, low back disability, and lumbar range of motion. The repeated measurement ANOVA was used for inter- and intragroup comparison, with significance at P≤.05.

RESULTS

The study comprised a sample of 40 patients with low back pain; 12 (40%) were female and 28 (60%) were male, with a mean age of 37.85 (SD 12.15) years. The pre- and posttest mean pain scores were 7.60 (SD 1.84) and 4.20 (SD 1.62) in group A, 6.60 (SD 1.776) and 5.90 (SD 1.73) in group B, 6.90 (SD 1.73) and 5.40 (SD 1.07) in group C, and 7.10 (SD 1.53) and 3.60 (SD 0.97) in group D, respectively. The mean pain score differences of group D (combining the Reflex Ridge and Body Ball games with back-strengthening exercises) compared to groups A, B, and C were -.60 (P=.76), -2.30 (P<.001), and -1.80 (P=.03), respectively. Regarding the range of motion, the forward lumbar flexion mean differences of group D compared to groups A, B, and C were 3.80 (P=.21), 4.80 (P=.07), and 7.40 (P<.001), respectively. Similarly, the right lateral lumbar flexion mean differences of group D compared to groups A, B, and C were 2.80 (P=.04), 5.20 (P<.001), and 4.80 (P<.001), respectively. The left lateral lumbar flexion mean differences of group D compared to groups A, B, and C were 2.80 (P<.001), 4.80 (P=.02), and 2.20 (P<.001). respectively, showing significant pre- and posttreatment effects.

CONCLUSIONS

VR exercises had statistically significant effects on improving pain, low back disability, and range of motion in all groups, but the combination of Reflex Ridge and Body Ball games with back-strengthening exercises had dominant effects compared to the other groups.

TRIAL REGISTRATION

Iranian Registry of Clinical Trial IRCT20200330046895N1; https://en.irct.ir/trial/46916.

Effect of integrated exercise therapy and psychosocial interventions on self-efficacy in patients with chronic low back pain: A systematic review

OBJECTIVE

Investigate if integrated exercise and psychosocial (EP) interventions effect self-efficacy to manage pain and self-efficacy for physical functioning compared to alternate interventions, usual care, waitlists and attention controls for individuals with chronic low back pain (CLBP).

METHODS

MEDLINE, Embase, CINAHL, Web of Science, PsychINFO, PEDro, and Cochrane Library were searched. Included randomized controlled trials utilized an EP intervention for CLBP and measured self-efficacy. Independent reviewers screened abstracts, reviewed full-texts, extracted data, and assessed risk of bias. GRADE, synthesis without meta-analysis, and ranges of effects (Hedges' g) were used.

RESULTS

2207 Participants were included (22-studies). EP interventions positively effected self-efficacy to manage pain short-term compared to usual care (range of effects: -0.02, 0.94) and controls (range of effects: 0.69, 0.80) and intermediately compared to usual care (range of effects: 0.11, 0.29); however, no differences were found when compared to alternate interventions. EP interventions positively effected self-efficacy for physical functioning short-term compared to alternate interventions (range of effects: 0.57, 0.71), usual care (range of effects: -0.15, 0.94), and controls (range of effects: 0.31, 0.56), and intermediately compared to alternate interventions (1-study, effect: 0.57) and controls (1-study, effect: 0.56). Conclusions were limited by low to very low-quality-evidence often from risk of bias, imprecision, and clinical/statistical heterogeneity.

CONCLUSIONS

EP interventions may be more effective short-term for self-efficacy to manage pain than usual care and waitlists, but not alternate interventions. EP interventions may be effective for self-efficacy for physical functioning at short- and intermediate-term compared to alternate interventions, usual care, waitlist and attention controls. Considerations for future research include methods for blinding and measurement of self-efficacy for physical functioning.

The association between self-efficacy on function and pain outcomes among patients with chronic low back pain managed using the McKenzie approach: a prospective cohort study

INTRODUCTION

Self-efficacy is a determinant of function and pain outcomes in patients with chronic low back pain receiving physiotherapy. The McKenzie approach is an effective intervention for patients with back pain that may affect self-efficacy. Study aims were to determine if, among patients with back pain being managed by McKenzie-credentialed physiotherapists: intake self-efficacy is correlated with intake function and pain; intake self-efficacy is associated with changes in function and pain during treatment; self-efficacy improves during treatment; and improvements in self-efficacy during treatment are associated with improvements in function and pain at discharge.

METHODS

Two-hundred-eighty-two subjects with chronic low back pain seen by McKenzie-credentialed clinicians provided data on self-efficacy, function and pain at intake and discharge.

RESULTS

Self-efficacy was correlated with function and pain at intake; however, intake self-efficacy was not associated with function or pain outcomes. Self-efficacy increased during treatment. This increase was associated with improvements in function and pain at discharge.

CONCLUSION

While intake self-efficacy was associated with function and pain when initiating physiotherapy, it did not result in improved treatment outcomes. Specific interventions may be necessary to improve self-efficacy. The increases in self-efficacy observed during treatment were associated with improvements in function and pain outcomes at discharge.

The effect of exercise engagement on low back disability at 12-months is mediated by pain and catastrophizing in a community sample of people with chronic low back pain

Despite being a first-line treatment recommendation, there is uncertainly for how exercise helps people with chronic low back pain. We designed this study to examine how exercise might help people with chronic low back pain by following a large community sample for 1-year. Qualitative questionnaires and self-report measures were collected every 3-months for 1-year in 400 people with chronic low back pain. People were not provided any specific treatment advice as part of this study but were allowed to engage with any normal physical activity, treatment, or medication as part of their normal life. Exercise engagement was defined from inspection of participant qualitative responses, according to minimum acceptable levels of exercise that elicit symptom reduction. Multiple mediation analysis was performed to examine the effect of exercise engagement on disability through the proposed mediators (pain, fear, catastrophizing, depression, anxiety, self-efficacy). The significant effect of exercise engagement on reductions in disability at 6- and 12-months was explained through pain and catastrophizing. People with chronic low back pain who reported worsening of symptoms over the year had similar reporting of exercise throughout the 12-months to people who had improvements in disability. Exercise can reduce disability through the effect on pain and catastrophizing, but how this effect occurs (i.e., an active or passive component of exercise) is unclear.

"I don't want to be a burden" A qualitative study of the beliefs of women with chronic low back pain in relation to their painful experience

BACKGROUND

Women's pain is still poorly understood. Moreover, maladaptive pain beliefs contribute to the disability associated with low back pain and play a key role in the transition from acute to chronic symptoms.

OBJECTIVES

To explore the beliefs of women with non-specific chronic low back pain in terms of nature of symptoms, fears associated with pain, expectations for recovery, family, social and work-related limitations, and perceived self-efficacy.

DESIGN AND METHODS

A qualitative study with an interpretative approach was undertaken. Face-to-face, semi-structured individual interviews were performed. Study participants were 10 women with non-specific chronic low back pain living in the Metropolitan Region of Chile. Thematic analysis was used to analyze the data. A deductive process was used to code the text and categorize the data.

RESULTS

Participants described maladaptive beliefs about pain, leading to fearful attitudes and low expectations for recovery. These beliefs seemed to perpetuate pain and limit engagement in daily tasks and meaningful activities. Some of these beliefs were associated with information provided by healthcare professions. Despite having maladaptive beliefs, women perceived themselves as self-effective.

CONCLUSION

Women with chronic low back pain described a range of different pain beliefs across a complex categorial structure. The contents of such structure may interfere with their decisions about therapeutic options. Their beliefs were often ungrounded in scientific principles, even if the information may have been provided by healthcare providers. Physical therapists would benefit from these findings to improve communication with their patients and assess the role of beliefs in decision-making.

Which psychosocial factors are related to severe pain and functional limitation in patients with low back pain?: Psychosocial factors related to severe low back pain

BACKGROUND

Low back pain (LBP) is a global public health issue. Psychosocial factors are linked to LBP. However, there is a lack of knowledge about the relation of psychosocial factors to clinical outcomes of patients with severe LBP.

OBJECTIVE

To investigate the relationship between specific psychosocial factors with severe pain and functional limitation of patients with LBP.

METHODS

A cross-sectional study of 472 participants with LBP was conducted. Participants completed self-reported questionnaires, including psychosocial factors, characteristics of pain, and functional limitations. Two multivariable logistic regression models were performed with severe pain intensity (≥ 7 out of 10) and functional limitation (≥ 7 out of 10) (dependent variables) and 15 psychosocial factors (independent variables).

RESULTS

One hundred twenty-five (26.5%) participants had severe LBP. Patients with catastrophising symptoms were 2.21 [95%Confidence Interval (CI): 1.30, 3.77] times more likely to have severe pain and 2.72 (95%CI: 1.75, 4.23) times more likely to have severe functional limitation than patients without catastrophising symptoms. Patients with maladaptive beliefs about rest were 2.75 (95%CI: 1.37, 5.52) times more likely to present with severe pain and 1.72 (95%CI: 1.04, 2.83) times more likely to have severe functional limitation. Patients with kinesiophobia were 3.34 (95%CI: 1.36, 8.24) times more likely to present with severe pain, and patients with social isolation were 1.98 (95%CI: 1.25, 3.14) times more likely to have severe functional limitation.

CONCLUSION

Catastrophising, kinesiophobia, maladaptive beliefs about rest, and social isolation are related to unfavourable clinical outcomes of patients with LBP.

Self-efficacy and fear of pain to movement in chronic low back pain: an intervention developed by nurses

OBJECTIVE

To test the effect of interventions to chronic low back pain developed by nurses in the Program to Increase Self-efficacy and Reduce the Fear of Pain and Avoidance of Movement.

METHOD

Clinical trial, with 81 patients, carried out in 2016, at the Pain Outpatient Clinic in São Luís, Maranhão, Brazil. The groups received: A (education and exposure), B (education) and C (control). Chi-square, Fisher's Exact, ANOVA and Kruskal Wallis tests were performed.

RESULTS

Patients in groups A and B improved self-efficacy, anxiety, depression, and disability, compared to group C. The reduction in fear of pain and avoidance of movement was greater in Group A, which also showed a decrease in current pain and overall scores compared to Group B and C.

CONCLUSION

Education was effective in increasing the Self-Efficacy Belief. For the Belief of Fear of Pain and Avoidance of Movement and pain intensity, the association with exposure showed better results.

The Moderating Effect of Treatment Engagement on Fear-avoidance Beliefs in People With Chronic Low Back Pain

OBJECTIVES

The fear-avoidance model (FAM) is used to explain pain-related disability and design targeted interventions for people with chronic low back pain. While treatment engagement is critical, it is unknown how treatment moderates the FAM.

METHODS

This study examined whether pathways within the FAM were moderated by treatment engagement in 508 people with chronic low back pain. Measures of disability, pain, fear, catastrophizing, anxiety, depression, and self-efficacy were collected through self-report, and descriptors of treatment engaged within the last month (physical activity type, medication, allied and medical health practitioner). Moderated mediation analyses were performed to examine the conditional effect of treatment engagement on fear-avoidance pathways.

RESULTS

The conditional effect of anxiety on disability was only significant for people who did not report any treatment engagement in the last month (B=1.03, 95% confidence interval: 0.53-1.53, P<0.001). The effect of depression increased for people reporting more different types of treatment in the last month (1 level of treatment increase, B=0.27, 95% confidence interval: 0.05-0.50, P=0.019). Conversely, greater treatment engagement had a positive influence on the mediating effect of self-efficacy. That is, the effect of pain on efficacy reduced with greater treatment engagement, with a concomitant increased effect of self-efficacy on disability.

DISCUSSION

Clinicians should explore the history and rationale behind patient treatment seeking behavior to ensure this is not reinforcing the negative effects of depressive symptoms on pain-related disability.

Changes in Pain Self-Efficacy, Coping Skills, and Fear-Avoidance Beliefs in a Randomized Controlled Trial of Yoga, Physical Therapy, and Education for Chronic Low Back Pain

OBJECTIVE

We evaluated exercise interventions for cognitive appraisal of chronic low back pain (cLBP) in an underserved population.

METHODS

We conducted a secondary analysis of the Back to Health Trial, showing yoga to be noninferior to physical therapy (PT) for pain and function outcomes among adults with cLBP (n = 320) recruited from primary care clinics with predominantly low-income patients. Participants were randomized to 12 weeks of yoga, PT, or education. Cognitive appraisal was assessed with the Pain Self-Efficacy Questionnaire (PSEQ), Coping Strategies Questionnaire (CSQ), and Fear-Avoidance Beliefs Questionnaire (FABQ). Using multiple imputation and linear regression, we estimated within- and between-group changes in cognitive appraisal at 12 and 52 weeks, with baseline and the education group as references.

RESULTS

Participants (mean age = 46 years) were majority female (64%) and majority Black (57%), and 54% had an annual household income <$30,000. All three groups showed improvements in PSEQ (range 0-60) at 12 weeks (yoga, mean difference [MD] = 7.0, 95% confidence interval [CI]: 4.9, 9.0; PT, MD = 6.9, 95% CI: 4.7 to 9.1; and education, MD = 3.4, 95% CI: 0.54 to 6.3), with yoga and PT improvements being clinically meaningful. At 12 weeks, improvements in catastrophizing (CSQ, range 0-36) were largest in the yoga and PT groups (MD = -3.0, 95% CI: -4.4 to -1.6; MD = -2.7, 95% CI: -4.2 to -1.2, respectively). Changes in FABQ were small. No statistically significant between-group differences were observed on PSEQ, CSQ, or FABQ at either time point. Many of the changes observed at 12 weeks were sustained at 52 weeks.

CONCLUSION

All three interventions were associated with improvements in self-efficacy and catastrophizing among low-income, racially diverse adults with cLBP.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01343927.

Income as a Predictor of Self-Efficacy for Managing Pain and for Coping With Symptoms Among Patients With Chronic Low Back Pain

OBJECTIVES

The purpose of this study was to evaluate pain self-efficacy (PSE) and coping self-efficacy (CSE) for people with chronic low back pain (CLBP), and to assess whether lower income may be associated with less PSE and CSE in the United States.

METHODS

We conducted a cross-sectional study using survey data collected between June 2016 and February 2017 from n = 1364 patients with CLBP from chiropractic clinics in the United States to measure the relationship between income and both types of self-efficacy. We created 4 multivariate models predicting PSE and CSE scores. We used both a parsimonious set of covariates (age, sex) and a full set (age, sex, education, neck pain comorbidity, catastrophizing, and insurance). We also calculated effect sizes (Cohen's d) for unadjusted differences in PSE and CSE score by income.

RESULTS

Lower income was associated with lower PSE and CSE scores across all 4 models. In the full models, the highest-income group had an average of 1 point (1-10 scale) higher PSE score and CSE score compared to the lowest income group. Effect sizes for the unadjusted differences in PSE and CSE scores between the highest and lowest income groups were 0.94 and 0.84, respectively.

CONCLUSIONS

Our findings indicate that people with lower income perceive themselves as less able to manage their pain, and that this relationship exists even after taking into account factors like health insurance and educational attainment. There is a need to further investigate how practitioners and policymakers can best support low-income patients with chronic pain.

Screening for Yellow Flags in Orthopaedic Physical Therapy: A Clinical Framework

BACKGROUND

Psychological factors influence or are associated with physical function, pain, and health care costs among individuals with musculoskeletal pain conditions. Recent clinical practice guidelines recommend screening for psychological factors (also referred to as "yellow flags") in physical therapy practice to help understand prognosis and inform shared decision making for treatment.

CLINICAL QUESTION

Despite the urgings of clinical practice guidelines and evidence of the influence of psychological factors on clinical outcomes, screening for yellow flags is uncommon in clinical practice. Clinicians may feel uncertain about how to integrate screening tools into clinical practice, and how screening results might inform decision making and care coordination.

KEY RESULTS

We outline a 3-step framework for routine yellow flag screening in physical therapy practice: (1) establish a standard first-line screening instrument and process, (2) interpret the results to inform shared decision making, and (3) monitor treatment progress. Four case examples illustrate how yellow flag screening can help clinicians and patients decide whether the patient might benefit most from standard physical therapy, psychologically informed physical therapy, psychologically informed physical therapy with referral to another health care provider, or immediate referral.

CLINICAL APPLICATION

Consider incorporating a standard yellow flag screening process into usual musculoskeletal health care. We present a framework to guide yellow flag screening in practice (1) to help inform treatment pathway selection and (2) to enhance interdisciplinary communication. J Orthop Sports Phys Ther 2021;51(9):459-469. doi:10.2519/jospt.2021.10570.

Producing Clinically Meaningful Reductions in Disability: A Causal Mediation Analysis of a Patient Education Intervention

Patient education is recommended as first-line care for low back pain (LBP), although its efficacy for providing clinically meaningful reductions in disability has been questioned. One way to improve treatment effects is to identify and improve targeting of treatment mechanisms. We conducted a pre-planned causal mediation analysis of a randomized, placebo-controlled trial investigating the effectiveness of patient education for patients with acute LBP. 202 patients who had fewer than six-weeks' duration of LBP and were at high-risk of developing chronic LBP completed two, one-hour treatment sessions of either intensive patient education, or placebo patient education. 189 participants provided data for the outcome self-reported disability at three-months and the mediators, pain self-efficacy, pain catastrophizing, and back beliefs at one-week post treatment. This causal mediation analysis found that pain catastrophizing (mediated effect, -0.64; 95% Confidence Interval [CI], -1.31 to -0.15) and back beliefs (mediated effect, -0.51; 95% CI, -1.15 to -0.02) partly explained the effect of patient education on disability but pain self-efficacy did not (mediated effect, -0.40; 95% CI -1.13 to 0.28). Considering the mediator-outcome relationship, patient education would need to induce an 8 point difference on the pain self-efficacy questionnaire (0-60); an 11 point difference on the back beliefs questionnaire (9-45); and a 21 point difference on the pain catastrophizing scale (0-52) to achieve a minimally clinically important difference of 2 points on the Roland Morris Disability Questionnaire (0-24). PERSPECTIVE: Understanding the mechanisms of patient education can inform how this treatment can be adapted to provide clinically meaningful reductions in disability. Our findings suggest that adapting patient education to better target back beliefs and pain self-efficacy could result in clinically meaningful reductions in disability whereas the role of pain catastrophizing in acute LBP is less clear.

The Relationship of the Therapeutic Alliance to Patient Characteristics and Functional Outcome During an Episode of Physical Therapy Care for Patients With Low Back Pain: An Observational Study

OBJECTIVE

Research supports the relevance of the therapeutic alliance (TA) between patients and physical therapists on outcomes, but the impact of TA during routine physical therapist practice has not been quantified. The primary objective of this study was to examine the relationship between TA assessed during a physical therapy episode of care for patients with low back pain and functional outcome at the conclusion of care. The secondary objective was to examine psychometric properties of the Working Alliance Inventory-Short Revised (WAI-SR) form, a patient-reported TA measure.

METHODS

This study was a retrospective analysis of prospectively collected data from 676 patients (mean [SD] age = 55.6 [16.1] y; 55.9% female) receiving physical therapy for low back pain in 45 outpatient clinics from 1 health system in the United States. Participating clinics routinely collect patient-reported data at initial, interim, and final visits. The lumbar computer-adapted test (LCAT) was used to evaluate functional outcome. The TA was assessed from the patient's perspective at interim assessments using the WAI-SR, bivariate correlations were examined, and regression models were examined if interim WAI-SR scores explained outcome variance beyond a previously validated multivariate prediction model. Internal consistency and ceiling effects for the WAI-SR were examined.

RESULTS

Interim WAI-SR scores were not correlated with patient characteristics or initial LCAT, but they were correlated with final LCAT and LCAT change from initial to final assessment. WAI-SR total score (adjusted R2 = 0.36), and Task (adjusted R2 = 0.38) and Goal subscales (adjusted R2 = 0.35) explained additional variance in outcome beyond the base model (adjusted R2 = 0.33). Internal consistency was higher for WAI-SR total score (α = .88) than for subscales (α = .76-.82). Substantial ceiling effects were observed for all WAI-SR scores (27.2%-63.6%).

CONCLUSION

Findings support the importance of TA in physical therapist practice. Measurement challenges were identified, most notably ceiling effects.

IMPACT

This study supports the impact of the patient-physical therapist alliance on functional outcome. Results extend similar findings from controlled studies into a typical physical therapist practice setting. Better understanding of the role of contextual factors including the therapeutic alliance might be key to improving the magnitude of treatment effect for discrete physical therapist interventions and enhancing clinical outcomes of physical therapy episodes of care.

Assessment of measurement properties of the Brazilian-Portuguese version of the low back activity confidence scale (LoBACS) in patients with chronic low back pain

The Low Back Activity Confidence Scale (LoBACS) assesses the self-efficacy to perform activities in individuals with chronic low back pain (CLBP). As self-efficacy appears to directly influence the patient’s functional capacity and prognosis, it is important to develop a scale that evaluates this attribute to guide treatment strategy and monitor the clinical course of patients. This study aimed to evaluate the reliability, construct validity, and responsiveness of the Brazilian version of the LoBACS. The scale was applied to 112 male and female patients (age, 18–65 years) with specific and nonspecific CLBP. For evaluating the interobserver reliability, the scale was applied twice on the first evaluation day by two trained evaluators (A and B). Within 48–72 h of the first evaluation, assessor A reapplied the scale to evaluate intraobserver reliability (test–retest), which was analyzed by intraclass correlation coefficient (ICC). The first LoBACS applied in the baseline evaluation was also used to assess the construct validity of the scale by factor analysis. For responsiveness, the scale was applied 5 times at 2-week intervals and the change in scores was analyzed by the repeated measures ANOVA. Although factor analysis indicated three subscales, they did not present acceptable values of convergent and divergent validity. Reliability ranged from good to excellent, with ICC values of .90 (95% CI, .84; .93) and .85 (95% CI, .77; .91) for inter- and intraobserver variability for total score. Moreover, the total score was responsive in all comparisons, with no floor or ceiling effects. Thus, only the total score of the Brazilian version of LoBACS proved to be reliable, valid, and responsive.