Acute low back pain: pain-related fear and pain catastrophizing influence physical performance and perceived disability

Pain-related fear and pain catastrophizing are associated with disability and actual performance in chronic pain patients. In acute low back pain (LBP), little is known about the prediction of actual performance or perceived disability by pain-related fear and pain catastrophizing. This experimental, cross-sectional study aimed at examining whether pain-related fear and pain catastrophizing were associated with actual performance and perceived disability. Ninety six individuals with an episode of acute LBP performed a dynamic lifting task to measure actual performance. Total lifting time was used as outcome measure. The results show that pain-related fear, as measured with the Tampa Scale for Kinesiophobia, was the strongest predictor of this physical task. Using the Roland Disability Questionnaire as a measure of perceived disability, both pain-related fear and pain catastrophizing, as measured with the Pain Catastrophizing Scale, were significantly predictive of perceived disability and more strongly than pain intensity was. The results of the current study suggest that pain-related fear is an important factor influencing daily activities in individuals suffering an episode of acute LBP. The study results have important clinical implications, especially in the development of preventive strategies for chronic LBP.     

A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up

OBJECTIVE: This study reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain (LBP) and assesses the influence of doctor type and pain duration on clinical outcomes. DESIGN: Prospective, longitudinal, nonrandomized, practice-based, observational study. SETTING: Fifty-one chiropractic and 14 general practice community clinics. SUBJECTS: A total of 2870 acute and chronic ambulatory patients with LBP of mechanical origin. METHODS: Sixty chiropractic (DC) and 111 general practice (MD) physicians participated. Primary outcomes were pain, using a 100-point visual analogue scale (VAS), and functional disability, using the Revised Oswestry Disability Questionnaire. These were measured at baseline and 8 time points. Regression analysis compared acute and chronic DC and MD patients after correcting for baseline differences in the 4 cohorts. RESULTS: Most improvement was seen by 3 months and sustained for 1 year; exacerbation was seen thereafter. Acute patients demonstrated greater relief at all time points. A clinically important advantage for chiropractic patients was seen in chronic patients in the short-term (>10 VAS points), and both acute and chronic chiropractic patients experienced somewhat greater relief up to 1 year (P<.000). The advantage for DC care was prominent for chronic patients with leg pain below the knee (P<.001). More than 50% of chronic patients had over 50 days of pain in the third year. CONCLUSION: Study findings were consistent with systematic reviews of the efficacy of spinal manipulation for pain and disability in acute and chronic LBP. Patient choice and interdisciplinary referral should be prime considerations by physicians, policymakers, and third-party payers in identifying health services for patients with LBP.     

Movement-Evoked Pain Versus Widespread Pain: A Longitudinal Comparison in Older Adults With Chronic Low Back Pain From the Delaware Spine Studies

It is currently unknown which pain-related factors contribute to long-term disability and poorer perceived health among older adults with chronic low back pain (LBP). This investigation sought to examine the unique influence of movement-evoked pain (MeP) and widespread pain (WP) on longitudinal health outcomes (ie, gait speed, perceived disability, and self-efficacy) in 250 older adults with chronic LBP. MeP was elicited with 3 standardized functional tests, while presence of WP was derived from the McGill Pain Map. Robust regression with HC3 standard errors was used to examine associations between these baseline pain variables and health outcomes at 12-month follow-up. Covariates for these models included age, sex, body mass index, resting and recall LBP intensity, LBP duration, depression, pain catastrophizing, and baseline outcome (eg, baseline gait speed). Greater MeP was independently associated with worse 12-month LBP-related disability (b = .384, t = 2.013, P = .046) and poorer self-efficacy (b = -.562, t = -2.074, P = .039); but not gait speed (P > .05). In contrast, WP and resting and recall LBP intensity were not associated with any prospective health outcome after adjustment (all P > .05). Compared to WP and resting and recall LBP intensity, MeP is most strongly related to longitudinal health outcomes in older adults with chronic LBP.PerspectiveThis article establishes novel independent associations between MeP and worse perceived disability and self-efficacy at 12-months in older adults with chronic LBP. MeP likely has biopsychosocial underpinnings and consequences and may therefore be an important determinant of health outcomes in LBP and other geriatric chronic pain populations.     

Responsiveness of pain, active range of motion, and disability in patients with acute nonspecific low back pain

Many parameters are now used for investigations in clinical settings, such as pain, active range of motion (AROM), and disability, but it is not yet known which parameters are responsive in patients with acute nonspecific low back pain (LBP). This study aimed to investigate the responsiveness of pain, AROM, and disability in patients with acute nonspecific LBP. Fifty subjects were assessed for pain, AROM, and disability at baseline and after 6 weeks. The effect size (ES) was calculated for each parameter. Also, patient’s perception of change was collected after 6 weeks for correlating it with change scores for each parameter. The most responsive parameter for detecting the change in patients with acute nonspecific LBP was pain (ES, 1.57) and disability (ES, 0.93). However, AROM was proved to be less responsive. This study indicated that pain and disability were responsive in detecting the changes in patients with acute nonspecific LBP over time.     

Diagnostic uncertainty and recall bias in chronic low back pain

Patients’ beliefs about the origin of their pain and their cognitive processing of pain-related information have both been shown to be associated with poorer prognosis in low back pain (LBP), but the relationship between specific beliefs and specific cognitive processes is not known. The aim of this study was to examine the relationship between diagnostic uncertainty and recall bias in 2 groups of chronic LBP patients, those who were certain about their diagnosis and those who believed that their pain was due to an undiagnosed problem. Patients (N = 68) endorsed and subsequently recalled pain, illness, depression, and neutral stimuli. They also provided measures of pain, diagnostic status, mood, and disability. Both groups exhibited a recall bias for pain stimuli, but only the group with diagnostic uncertainty also displayed a recall bias for illness-related stimuli. This bias remained after controlling for depression and disability. Sensitivity analyses using grouping by diagnosis/explanation received supported these findings. Higher levels of depression and disability were found in the group with diagnostic uncertainty, but levels of pain intensity did not differ between the groups. Although the methodology does not provide information on causality, the results provide evidence for a relationship between diagnostic uncertainty and recall bias for negative health-related stimuli in chronic LBP patients.     

Fear-avoidance beliefs about back pain in patients with acute LBP

OBJECTIVE: We aimed to assess fear-avoidance beliefs in patients with acute low back pain (LBP) and to identify features of patients and general practitioners (GPs) associated with patients' fear-avoidance beliefs. METHODS: A cross-sectional study conducted in primary care practice in France. A total of 709 GPs completed a self-administered questionnaire assessing fear-avoidance beliefs [the Fear-Avoidance Beliefs Questionnaire (FABQ)] and 2,727 patients with acute LBP completed a self-administered questionnaire assessing pain, perceived handicap and disability (on the Quebec Back Pain Disability Scale) and fear-avoidance beliefs (on the FABQ). RESULTS: Patients' FABQ mean scores were 16.8+/-5.0 for physical activities (FABQ Physical) and 19.5+/-10.9 for occupational activities (FABQ Work). From multivariate analysis, the following factors were associated with patients' FABQ Phys and Work scores: having a GP with a high rating on the FABQ Phys (P=0.0001 and 0.02 for FABQ Phys and Work, respectively), no sport practice (vs. occasional: P=0.0003 and 0.03; vs. usual/competition: P=0.0001 and 0.004), disability score (Quebec) (P=0.0001 for both FABQ scores), and pain intensity (P=0.0012 and 0.0013). CONCLUSIONS: High levels of fear-avoidance beliefs occur early in LBP patients, and key messages on this topic should probably be delivered at a very early stage of the disease.     

Validity of weekly recall ratings of average pain intensity in neck pain patients

ObjectiveRatings of usual pain over a period of 1 week are commonly used to rate a patient's usual level of pain intensity. This study investigated the validity of weekly recall pain ratings and biasing effects of pain levels on these ratings.MethodsSeventy-eight patients presenting to a chiropractic outpatient clinic with nonspecific neck pain completed a 7-day diary rating their pain 4 times each day on an 11-point numerical rating scale. From these 28 ratings, the patients' “actual average” pain was computed. On day 8, patients were asked to rate their current pain, as well as recall their pain “on average,” at its “worst,” and at its “least” over the previous week.ResultsRecall of average pain over the previous week was shown to be a valid measure using ratings of actual pain as the criterion standard (Pearson r = 0.95). The error between actual and recall readings was random and consistent across all levels of actual pain. Patients were also able to accurately recall their pain at its worst (r = 0.93) and at its least (r = 0.92) over the preceding week. In regression analyses, there were no appreciable biasing effects on the recall of average pain of either current pain at the time of recall, or of pain at its worst or at its least during the recall period.ConclusionThese results suggest that recall ratings of pain intensity may be valid for use in clinical research and practice on patients with nonspecific neck pain.     

Screening for yellow flags in first-time acute low back pain: reliability and validity of a Norwegian version of the Acute Low Back Pain Screening Questionnaire

OBJECTIVES: The purpose of this study was to evaluate the reliability and construct and predictive validity of the Norwegian version of the Acute Low Back Pain Screening Questionnnaire (ALBPSQ). METHODS: A prospective study with a 12-month follow-up was conducted on 123 patients with acute low back pain (LBP) seeking help in primary health care for the first time and 50 patients with chronic LBP for more than 3 months. RESULTS: Test-retest reliability was high with intraclass correlation coefficients of 0.90, minimal detectable change of 12 points (of a total score of 210), and coefficient of variation of 4%. Internal consistency was 0.95. Principal-components analysis revealed 3 factors explaining 49% of the variance. The ALBPSQ score correlated highly (r> or =0.60) with disability variables, moderately (0.30相似文献   

Prognostic factors in first-time care seekers due to acute low back pain.

There is limited knowledge on prognostic factors for developing chronic low back pain (LBP) at an early stage of LBP. The objectives of this study were to investigate the clinical course of pain and disability, and prognostic factors for non-recovery after 1-year, in patients seeking help for the first time due to acute LBP. An inception cohort study included 123 patients with acute LBP lasting less than 3 weeks and consulting primary care for the first time. Main outcome measures were pain intensity, Roland-Morris disability questionnaire (RMQ), and sickness absence. Eleven patients (9%) did not return for the 12-month follow-up. There were large and significant reductions in pain intensity (P<0.001) and RMQ scores (P<0.001) during follow-up. Patients with neurological signs showed significantly less improvement in pain (P=0.001) and RMQ (P=0.004) compared with those without neurological signs. The proportions with sickness absence due to LBP at 6, 9, and 12 months were 7%, 8%, and 9%, respectively. At 12 months, 17% of patients had not fully recovered. Multivariate logistic regression analyses showed that high scores on a psychosocial screening (acute low back pain screening questionnaire) and emotional distress (Hopkin's symptom check list) were significantly associated with non-recovery at 12 months, with odds ratios of 4.4 (95% confidence interval 1.1-17.4) and 3.3 (1.1-10.2), respectively.     

Decline in physical activity, disability and pain-related fear in sub-acute low back pain.

AIM OF INVESTIGATION: To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub-acute back pain. METHODS: Patients with 4-7 weeks of non-specific low back pain (LBP) participated in this study. Their habitual physical activity level before the back pain started (H-PAL), their actual level of physical activity (PAL) and their perceived decline in the level of physical activity after the onset of pain (PAD) were assessed. The association between these physical activity related variables and perceived disability (QBPDS), fear of movement/(re)injury (TSK), pain catastrophizing (PCS) and pain intensity (VAS) was examined. The role of PAD as a mediator in the association between fear of movement/(re)injury and disability was examined by three linear regression analyses. RESULTS: 123 patients (66 male and 57 female) with a mean age of 44.1 years (SD=10.3) participated in this study. PAD was significantly correlated with disability, fear of movement/(re)injury, pain catastrophizing and pain intensity. PAD and PAL appeared more important in the explanation of disability in the subgroup of patients who were physically active before their back pain started. Generally, PAD indeed mediated the association between fear of movement/(re)injury and disability. CONCLUSIONS: The perceived decline in physical activity, rather than the current physical activity itself is important in the evaluation of the impact of activity related changes on disability in low back pain.     

The influence of non-specific low back pain on pressure pain thresholds and disability.

The purpose of this study was to investigate the pressure pain thresholds (PPTs) with respect to the Erector spinae and the hip muscles in 87 patients with subacute non-specific low back pain (LBP) and to evaluate the relationship between the PPTs and disability. In order to establish reference values, 64 healthy subjects were examined with respect to PPTs and used as a control group against the group of LBP patients. The mean PPT values of the Erector spinae and the hip at all examined points of the LBP group were significantly lower (p<0.001) in comparison to the PPT values of the healthy group. An exceptionally high difference (2.7 kg/cm2) was found at the L3 Erector spinae level. The correlation between having LBP or not in the whole group (n=151) and PPT, was highest at the L3 level of the Erector spinae (r=-0.710, p<0.001). When the group of patients with LBP was divided into two subgroups in terms of having an Oswestry disability index (ODI) lower than 40 ("moderate LBP disability") or an ODI higher than 40 ("severe LBP disability") it was surprising to notice that there was no significant difference between the PPTs of the Erector spinae and the hip musculature. This study has shown the possibility of the existence of muscular disorder in the lumbar part of the Erector spinae in patients with non-specific low back pain, but also reveals the strong inter-individual differences in muscular fibrosis sensitivity and pain behaviour related to gender.     

The prevalence and management of low back pain across adulthood: results from a population-based cross-sectional study (the MUSICIAN study)

The aim of the current study was to determine: the prevalence of low back pain (LBP) and associated disability; the frequency of consultation to general practice; whether there were differences in management by age. We conducted a cross-sectional population study in Aberdeen city and Cheshire County, UK. Participants were 15,272 persons aged 25 years and older. The 1-month period prevalence of LBP was 28.5%. It peaked at age 41-50 years, but at ages over 80 years was reported by 1 in 4 persons. Older persons were more likely to consult, and the prevalence of severe LBP continued to increase with age. Management by general practitioners differed by age of the patient. Older persons (> 70 vs ≤ 40 years) were more likely to only have been prescribed painkillers (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.28-2.35) or only pain killers with other medications (OR 1.45, 95% CI 1.07-1.98). They were less likely to be prescribed physiotherapy or exercise (OR 0.63, 95% CI 0.46-0.85) or to be referred to a specialist (OR 0.77, 95% CI 0.57-1.04). Older persons were more likely to have previously received exercise therapy for pain, were less likely to be enthusiastic about receiving it now (P<0.0001), and were less likely to think it would result in improved symptoms (P<0.0001). It is important that older persons, who have the highest prevalence of LBP with disability and are most likely to consult, are receiving optimal pharmacological and nonpharmacological management.     

Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability--a randomized, placebo-controlled, 3-month trial.

We evaluated etoricoxib, a novel COX-2-specific inhibitor, in 319 patients with chronic low back pain (LBP) in this double-blind, placebo-controlled trial. Patients were randomized to a 60 mg dose (n = 103) or 90 mg dose (n = 107) of etoricoxib, or placebo (n = 109), daily for 12 weeks. The primary endpoint was low back pain intensity scale (Visual Analog Scale of 0- to 100-mm) time-weighted average change from baseline over 4 weeks. Other endpoints included evaluation over 3 months of low back pain intensity scale, Roland-Morris Disability Questionnaire (RMDQ), low back pain bothersomeness scale, patient- and investigator-global assessments, Patient Health Survey (MOS SF-12), rescue acetaminophen use, and discontinuation due to lack of efficacy. Etoricoxib provided significant improvement from baseline versus placebo in pain intensity (4 weeks: 12.9 mm and 10.3 mm for 60-mg and 90-mg doses, P <.001 for each; 12 weeks: 10.5 mm and 7.5 mm for 60-mg and 90-mg doses, P =.001 and.018, respectively). Etoricoxib at either dose led to significant improvement in other endpoints, including RMDQ scores, bothersomeness scores and global assessments. Etoricoxib given once daily provided significant relief of symptoms, and disability associated with chronic LBP that was observed 1 week after initiating therapy, was maximal at 4 weeks, and was maintained over 3 months.     

The selfBACK artificial intelligence-based smartphone app can improve low back pain outcome even in patients with high levels of depression or stress

Background

selfBACK provides individually tailored self-management support for low back pain (LBP) via an artificial intelligence-based smartphone app. We explore whether those with depressive/stress symptoms can benefit from this technology.

Methods

Secondary analysis of the selfBACK randomized controlled trial (n = 461). Participants with LBP were randomized to usual care (n = 229), or usual care plus selfBACK (n = 232). Primary outcome: LBP-related disability (Roland–Morris Disability Questionnaire, RMDQ) over 9 months. Secondary outcomes: global perceived effect (GPE)/pain self-efficacy (PSEQ)/satisfaction/app engagement. Baseline depressive symptoms were measured using the patient health questionnaire (PHQ-8) and stress with the perceived stress scale (PSS). Outcomes stratified by baseline PHQ-8/PSS scores to assess associations across the whole cohort, and intervention versus control groups.

Results

Participants with higher levels of depressive/stress symptoms reported more baseline LBP-related disability (RMDQ 3.1; 1.6 points higher in most vs least depressed/stressed groups respectively); lower self-efficacy (PSEQ 8.1; 4.6 points lower in most vs least depressive/stressed groups respectively). LBP-related disability improved over time; relative risk of improvement in those with greatest depressive/stress symptoms versus nil symptom comparators at 9 months: 0.8 (95% CI: 0.6 to 1.0) and 0.8 (95% CI: 0.7 to 1.0) respectively. No evidence that different baseline levels of depressive/perceived stress symptoms are associated with different RMDQ/GPE/PSEQ outcomes. Whilst participants with higher PHQ-8/PSS were less likely to be satisfied or engage with the app, there was no consistent association among PHQ-8/PSS level, the intervention and outcomes.

Conclusions

The selfBACK app can improve outcomes even in those with high levels of depressive/stress symptoms and could be recommended for patients with LBP.

Significance

We have demonstrated that an app supporting the self-management of LBP is helpful, even in those with higher levels of baseline depression and stress symptoms. selfBACK offers an opportunity to support people with LBP and provides clinicians with an additional tool for their patients, even those with depression or high levels of stress. This highlights the potential for digital health interventions for chronic pain.     

The course of chronic and recurrent low back pain in the general population

Using latent class analysis (LCA), a previous study on patients attending primary care identified four courses of low back pain (LBP) over the subsequent 6 months. To date, no studies have used longitudinal pain recordings to examine the “natural” course of recurrent and chronic LBP in a population-based sample of individuals. This study examines the course of LBP in the general population and elaborates on the stability and criterion-related validity of the clusters derived. A random sample of 400 individuals reporting LBP in a population-based study was asked to complete a comprehensive questionnaire at the start and end of the year’s survey, and 52 weekly pain diaries in between. The latter were analyzed using LCA. 305 individuals returned more than 50% of the diaries. Four clusters were identified (severe persistent, moderate persistent, mild persistent, and fluctuating). The clusters differed significantly with regards to pain and disability. Assessment of cluster stability showed that a considerable proportion of patients in the “fluctuating” group changed their classification over time. Three of the four clusters describing the typical course of pain matched the clusters described previously for patients in primary care. Due to the population-based design, this study achieves, for the first time, a close insight into the “natural” course of chronic and recurrent low back pain, including individuals that did not necessarily visit the general practitioner. The findings will help to understand better the nature of this pain in the general population.     

The effects of a back rehabilitation programme for patients with chronic low back pain

AIM: The aim of this paper was to perform a pragmatic before-after analysis of a back rehabilitation programme (BRP) for patients with chronic low back pain (LBP). A total of 877 patients were recruited onto the BRP, which were carried out at four centres within the Wrightington, Wigan and Leigh NHS Trust. The BRP consisted of nine 2-hour group sessions of therapy run over 5 weeks and included 1 hour of exercise and 1 hour of education, advice problem solving and goal setting. METHOD: Using the Wilcoxen signed rank tests and paired t-tests levels of pain, disability, anxiety and depression were significantly reduced pre-post programme (P < 0.001). In addition, the levels of fitness and perceived control improved significantly (P < 0.001) suggesting that participants were better able to manage their LBP. CONCLUSION: Overall, the BRP proved to be effective in reducing pain, disability, anxiety and depression levels for people with chronic LBP. However, despite significant improvements in outcome measures only 50% of the patients completed the BRP and questionnaires post BRP. The implications of the findings are discussed with respect to modified programmes and alternative management for patients within different subgroups of LBP.     

Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain

OBJECTIVES: The Brief Pain Inventory (BPI) is a short, self-administered questionnaire that was developed for use in cancer patients. While most empirical research with the BPI has been in pain of that etiology, the questionnaire is increasingly evident in published studies of patients with non-cancer pain. The current research addresses the need for formal evaluation of the reliability and validity of the BPI for use in non-cancer pain patients. METHODS: Approximately 250 patients with arthritis or low back pain (LBP) self-administered a number of generic and condition-specific health status measures (including the BPI) in the clinic of their primary care provider at 2 time points: the initial clinic visit and the first visit following treatment. RESULTS: The reliability of BPI data collected from non-cancer pain patients was comparable to that reported in the literature for cancer patients and sufficient for group-level analyses (coefficient alphas were greater than 0.70). The factor structure of the BPI was replicated in this sample and the relationship of the BPI to generic measures of pain was strong. The BPI exhibited similar relationships to general and condition-specific measures of health as did a generic pain scale (SF-36 Bodily Pain). Finally, the BPI discriminated among levels of condition severity and was sensitive to change in condition over time in arthritis and LBP patients. DISCUSSION: Results support the validity of the BPI as a measure of pain in patients without cancer and, in particular, as a measure of pain for arthritis and LBP patients.