Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care

Many psychological factors have been suggested to be important obstacles to recovery from low back pain, yet most studies focus on a limited number of factors. We compared a more comprehensive range of 20 factors in predicting outcome in primary care. Consecutive patients consulting 8 general practices were eligible to take part in a prospective cohort study; 1591 provided data at baseline and 810 at 6 months. Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ). The relative strength of the baseline psychological measures to predict outcome was investigated using adjusted multiple linear regression techniques. The sample was similar to other primary care cohorts (mean age 44 years, 59% women, mean baseline RMDQ 8.6). The 20 factors each accounted for between 0.04% and 33.3% of the variance in baseline RMDQ score. A multivariate model including all 11 scales that were associated with outcome in the univariate analysis accounted for 47.7% of the variance in 6 months RMDQ score; rising to 55.8% following adjustment. Four scales remained significantly associated with outcome in the multivariate model explaining 56.6% of the variance: perceptions of personal control, acute/chronic timeline, illness identify and pain self-efficacy. When all independent factors were included, depression, catastrophising and fear avoidance were no longer significant. Thus, a small number of psychological factors are strongly predictive of outcome in primary care low back pain patients. There is clear redundancy in the measurement of psychological factors. These findings should help to focus targeted interventions for back pain in the future.     

The persistence of pain behaviors in patients with chronic back pain is independent of pain and psychological factors

The primary purpose of the present study was to examine the temporal stability of communicative and protective pain behaviors in patients with chronic back pain. The study also examined whether the stability of pain behaviors could be accounted for by patients’ levels of pain severity, catastrophizing, or fear of movement. Patients (n = 70) were filmed on two separate occasions (i.e., baseline, follow-up) while performing a standardized lifting task designed to elicit pain behaviors. Consistent with previous studies, the results provided evidence for the stability of pain behaviors in patients with chronic pain. The analyses indicated that communicative and protective pain behavior scores did not change significantly from baseline to follow-up. In addition, significant test-retest correlations were found between baseline and follow-up pain behavior scores. The results of hierarchical multiple regression analyses further showed that pain behaviors remained stable over time even when accounting for patients’ levels of pain severity. Regression analyses also showed that pain behaviors remained stable when accounting for patients’ levels of catastrophizing and fear of movement. Discussion addresses the potential contribution of central neural mechanisms and social environmental reinforcement contingencies to the stability of pain behaviors. The discussion also addresses how treatment interventions specifically aimed at targeting pain behaviors might help to augment the overall impact of pain and disability management programs.     

Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients.

This study aimed to determine whether self-efficacy beliefs mediated the relation between pain-related fear and pain, and between pain-related fear and disability in CLBP patients who exhibited high pain-related fear. In a cross-sectional design, 102 chronic low back pain (CLBP) patients completed measures for pain, disability, self-efficacy and pain-related fear (fear of movement and catastrophizing). Multistep regression analyses were performed to determine whether self-efficacy mediated the relation between pain-related fear and outcome (pain and/or disability). Self-efficacy was found to mediate the relation between pain-related fear and pain intensity, and between pain-related fear and disability. Therefore, this study suggests that when self-efficacy is high, elevated pain-related fear might not lead to greater pain and disability. However, in instances where self-efficacy is low, elevated pain-related fear is likely to lead to greater pain and disability. In view of these findings, we conclude that it is imperative to assess both pain-related fear and self-efficacy when treating CLBP patients with high pain-related fear.     

Post-trauma ratings of pre-collision pain and psychological distress predict poor outcome following acute whiplash trauma: a 12-month follow-up study

Patients with acute whiplash trauma were followed to examine if post-trauma ratings of pre-collision pain and psychological distress were associated with reduced work capability and neck pain at 12 months follow-up. The study included 740 consecutive patients (474 females, 266 males) referred from emergency departments or primary care after car accidents in four counties in Denmark. After the collision patients received a questionnaire on psychological distress, unspecified pain and socio-demographics and 12 months later a follow-up on work capability and neck pain was performed. Risk factors were identified by multiple logistic regression analysis. Factors associated with affected work capacity at the 12-month follow-up were pre-collision unspecified pain condition (OR=2.4, p=0.002) and socio-demographic characteristics: female gender, low educational level, unemployment and blue collar worker. Factors associated with considerable neck pain at follow-up were pre-collision unspecified pain (OR=3.5, p<0.000), pre-collision high psychological distress (OR=2.1, p=0.03) and socio-demographic characteristics: female gender and formal education >4 years. Pre-collision neck pain and severity of accident were not associated with poor outcome. In conclusion unspecified as opposed to specified pain (neck pain) before the collision is associated with poor recovery and high accumulation of pre-collision psychological distress is associated with considerable neck pain at follow-up. However, no conclusions on causality can be drawn. Personal characteristics before the collision are important for recovery and attention to pre-collision characteristics may contribute to the prevention of poor recovery after acute whiplash trauma.     

Effects of Qigong practice in office workers with chronic non-specific low back pain: A randomized control trial

ObjectiveTo investigate the effects of Qigong practice, Guan Yin Zi Zai Gong level 1, compared with a waiting list control group among office workers with chronic nonspecific low back pain (CNLBP).MethodsA randomized controlled trial was conducted at offices in the Bangkok Metropolitan Region. Seventy-two office workers with CNLBP were screened for inclusion/exclusion criteria (age 20–40 years; sitting period more than 4 h per day) and were allocated randomly into two groups: the Qigong and waiting list groups (n = 36 each). The participants in the Qigong group took a Qigong practice class (Guan Yin Zi Zai Gong level 1) for one hour per week for six weeks at their workstation. The participants were encouraged to conduct the Qigong exercise at home every day. The waiting list group received general advice regarding low back pain management. The primary outcomes were pain intensity, measured by the visual analog scale, and back functional disability, measured by the Roland and Morris Disability Questionnaire. The secondary outcomes were back range of motion, core stability performance index, heart rate, respiratory rate, the Srithanya Stress Scale (ST-5), and the global perceived effect (GPE) questionnaire.ResultsCompared to the baseline, participants in the Qigong group experienced significantly decreased pain intensity and back functional disability. No statistically significant difference in these parameters was found in the waiting list group. Comparing the two groups, Qigong exercise significantly improved pain intensity, back functional impairment, range of motion, core muscle strength, heart rate, respiratory rate, and mental status. The Qigong group also had a significantly higher global outcome satisfaction than the waiting list group.ConclusionQigong practice is an option for treatment of CNLBP in office workers.     

急性和亚急性下腰痛患者腰椎MRI影像学特征分析

目的:探讨急性和亚急性下腰痛患者腰椎MRI影像学特征及临床意义。方法:回顾性连续收集因下腰痛至本院就诊并行腰椎MRI检查患者177例。根据病程时间将患者分为亚急性下腰痛组(n=103)和急性下腰痛组(n=74例),另招募42例无下腰痛志愿者作为正常对照组。采用视觉模拟评分(visual anologue scale,VAS)评定患者腰痛程度。观察各组研究对象腰椎MRI影像学特征,包括:椎间盘退变、椎间盘突出、椎间盘膨出、纤维环后方高信号、Schmorl结节、椎体终板炎、小关节退变、小关节积液、棘间韧带高信号、皮下或椎后旁肌肉水肿、小关节退变等,对不同组间腰椎MRI影像学特征分布进行统计学比较分析。结果:与正常对照组相比,急性、亚急性下腰痛组研究对象椎间盘退变、椎间盘突出发生率较高(P0.05)。3组间椎间盘膨出、Schmorl结节、腰椎终板Modic改变发生情况差异无统计学意义。急性下腰痛组患者腰椎MRI纤维环后方高信号、棘间韧带高信号、皮下或椎后旁软组织肿胀发生率均高于亚急性下腰痛组和正常对照组(P0.05);亚急性下腰痛组患者中小关节退变和小关节积液发生率均高于急性下腰痛组和正常对照组(P0.05)。结论:椎间盘退变、突出是腰痛症状持续存在的原因;腰椎间盘局限性高信号、棘间韧带高信号和皮下或椎后旁软组织肿胀与急性下腰痛相关;小关节退变、小关节积液与亚急性下腰痛有关。     

Pain-related fear in acute low back pain: the first two weeks of a new episode.

The overall aim of this study was to explore the natural course of pain-related fear during the early stage of a new low back pain episode, using a prospective case series design. Specific research questions addressed the existence of typical patterns in individual time series of pain-related fear and sequential relationships between the occurrence of pain-related fear, pain and pain catastrophizing. Forty-four general practice patients who consulted their physician with a new episode of non-specific low back pain were recruited. They completed diaries on pain-related fear, pain and pain catastrophizing for 14 days following the consultation. Follow-up questionnaires on disability were completed at 3 months and 12 months. Time series analyses produced subgroups of patients with descending, stable and rising levels of pain-related fear over the 2-week period. These groups differed on baseline characteristics and outcome at follow-up. A time-shift between the occurrence of pain-events and pain-related fear or pain catastrophizing could not be demonstrated.In summary, these results fit in with previous findings in chronic patients. A relevant subgroup of patients who might benefit from early intervention could be identified. These findings support the need for further research into fear mechanisms in acute low back pain.     

Enhancing function in older adults with chronic low back pain: a pilot study of endurance training

OBJECTIVES: To assess the effectiveness of a bicycle endurance program in older adults with chronic low back pain (CLBP) and to identify correlates of exercise adherence. DESIGN: Prospective cohort. SETTING: Residential facilities and a tertiary care hospital. PARTICIPANTS: Adults with CLBP aged 55 years and older. Of 29 subjects who agreed to participate, 3 (10%) were deemed ineligible at baseline. Nineteen subjects (73%) were women, and the median age was 72 years. INTERVENTIONS: Subjects were assessed at baseline and at 6 and 12 weeks by using standardized questionnaires, physical examination, and endurance testing by a physical therapist. Subjects received a bicycle and instructions to exercise 3 times a week for 12 weeks at a set wattage. A trained rescarcher collected exercise data weekly.Main outcome measures The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the lumbar spinal stenosis symptom severity and function scales, and kilocalories were used to assess change. RESULTS: At baseline, subjects were moderately impaired (mean SF-36 physical function score, 52.6). Eighteen (65%) completed the trial. At 12 weeks, physical functioning (SF-36) improved by 11%, mental health (Mental Health Inventory 5-Item Questionnaire) improved by 14%, and CLBP symptoms decreased by 8%. Reasons for withdrawing included illness, family issues, and bicycle-related discomfort. CONCLUSIONS: The bicycle program was safe and effective for improving functional status and well-being.     

The relationship beween posture and back muscle endurance in industrial workers with flexion-related low back pain

This preliminary cross-sectional study was undertaken to determine if there were measurable relationships between posture, back muscle endurance and low back pain (LBP) in industrial workers with a reported history of flexion strain injury and flexion pain provocation. Clinical reports state that subjects with flexion pain disorders of the lumbar spine commonly adopt passive flexed postures such as slump sitting and present with associated dysfunction of the spinal postural stabilising musculature. However, to date there is little empirical evidence to support that patients with back pain, posture their spines differently than pain-free subjects. Subjects included 21 healthy industrial workers and 24 industrial workers with flexion-provoked LBP. Lifestyle information, lumbo-pelvic posture in sitting, standing and lifting, and back muscle endurance were measured. LBP subjects had significantly reduced back muscle endurance (P < 0.01). LBP subjects sat with less hip flexion, (P = 0.05), suggesting increased posterior pelvic tilt in sitting. LBP subjects postured their spines significantly closer to their end of range lumbar flexion in 'usual' sitting than the healthy controls (P < 0.05). Correlations between increased time spent sitting, physical inactivity and poorer back muscle endurance were also identified. There were no significant differences found between the groups for the standing and lifting posture measures. These preliminary results support that a relationship may exist between flexed spinal postures, reduced back muscle endurance, physical inactivity and LBP in subjects with a history of flexion injury and pain.     

Acute back pain management in primary care: a qualitative pilot study of the feasibility of a nurse-led service in general practice

OBJECTIVES: (1) To determine the acceptability of the Royal College of General Practitioner Guidelines to small samples of nurses, General Practitioners and acute back pain patients, (2) to determine what additional roles for nurses in the management of acute back pain in primary care might be acceptable to these samples, (3) to evaluate the responses of General Practitioners, nurses and patients to a suggested service model based on the RCGP Guidelines, (4) to identify opportunities for and barriers to the further development of such models and to obtain the appraisal of the above by an external group of assessors. METHODOLOGY: Using a qualitative design the pilot study included Primary Care (General Practitioners, Practice Nurses and Patients) with the main outcome measures as: appraisal questionnaires (for RCGP Guideline), qualitative content analysis of focus group narratives, and appraisal of process and outcomes by an external panel. RESULTS: Attitudes towards the RCGP guidelines were positive, but professionals and patients alike did not think their recommendations could be implemented with the current service provision in primary care. There was criticism by professionals of the capacity for a nurse-led service within practices. Access to chiropractors, osteopaths and/or specialist physiotherapists in National Health Service primary care was raised as a need by both groups. All members of the Advisory Panel approved the processes for the recruitment of participants, focus group questions and analysis. DISCUSSION: Barriers to implementation of the RCGP Guideline and to a nurse-led acute back pain service in general practice, were illustrated. These mainly relate to grossly inadequate capacity to deal with multidimensional patient needs, allowing progression to chronic pain states and much higher health care costs. There was a strong desire to include a different group of professionals in primary care. We recommend a local needs assessment and consideration of a national strategy for the implementation of the RCGP Guideline in primary care.     

青年慢性下腰痛患者腰背肌耐力比较研究

目的 :研究青年下腰痛患者腰背肌耐力的变化。方法 :应用CYBEX - 6 0 0 0型等速测试训练系统和肌电图测试腰痛组 (n =4 0 )和正常组 (n =4 0 )的腰背肌耐力指标 ,进行两组间比较。结果 :腰痛组腰背肌耐力比与正常组无差异 (P >0 .0 5 ) ;腰痛组腰背肌肌电图波幅低于正常组 (P <0 .0 5 )、时程大于正常组 (P <0 .0 5 ) ,腰痛组腰背肌肌电图波幅随时间衰减程度大于正常组 (P <0 .0 5 )、时程随时间延长程度大于正常组 (P <0 .0 5 )。结论 :青年下腰痛患者存在着明显的腰背肌静态耐力下降 ,腰背肌耐力比与下腰痛关系并不密切。     

Contributions of prognostic factors for poor outcome in primary care low back pain patients

Background: Back pain is common and some sufferers consult GPs, yet many sufferers develop persistent problems. Combining information on risk of persistence and prognostic indicator prevalence provides more information on potential intervention targets than risk estimates alone. Aims: To determine the proportion of primary care back pain patients with persistent problems whose outcome is related to measurable prognostic factors. Methods: Prospective cohort study of back pain patients (30–59 years) at five general practices in Staffordshire, UK (n =389). Baseline factors (demographic; episode duration; symptom severity; pain widespreadness; anxiety; depression; catastrophising; fear‐avoidance; self‐rated health) were assessed for their association with disabling and limiting pain after 12‐months. The proportion of those with persistent problems whose outcome was related to each factor was calculated. Results: Prevalence of prognostic factors ranged from 23% to 87%. Strongest predictors were unemployment (adjusted relative risk (RR) 4.2; 95% CI 2.0, 8.5) and high pain intensity (4.1; 1.7, 9.9). The largest proportions of persistent problems were related to high pain intensity (68%; 95% CI 27, 87%) and unemployment (64%; 33, 82%). Combining these indicated that 85% of poor back pain outcome is related to these two factors. Poor self‐rated health, functional disability, upper body pain and pain bothersomeness were related with outcome for over 40% of those with persistent problems. Conclusions: Several factors increased risk of poor outcome in back pain patients, notably high pain and unemployment. These risks in combination with high prevalence of risk factors in this population distinguish factors that can help identify targets or sub‐groups for intervention.     

腰痛患者肌卫星细胞生物学特性及其鉴定

目的：观察腰痛患者肌卫星细胞体外培养的生物学特性,探讨其在慢性腰痛中肌纤维损伤的修复作用。 方法：取腰骶部慢性骨筋膜间隔综合征所致腰痛患者活体竖脊肌组织块,采用I型胶原酶和胰蛋白酶两步消化法及差速贴壁法纯化肌卫星细胞,进行原代培养及传代培养,观察细胞形态及其传代能力,绘制生长曲线,结蛋白免疫组化染色鉴定肌卫星细胞。 结果： 纯化后肌卫星细胞生长良好,传代培养后增殖速度较原代培养快,6代以前形态较规则,8代以后逐渐老化,结蛋白鉴定呈阳性。 结论：慢性腰痛患者肌卫星细胞体外培养形态与正常人基本相同,但传代能力减弱,可能与修复受损肌纤维有关。     

Are changes in fear‐avoidance beliefs,catastrophizing, and appraisals of control,predictive of changes in chronic low back pain and disability?

Interventions for chronic low back pain (CLBP) often attempt to modify patients' levels of catastrophizing, their fear-avoidance beliefs, and their appraisals of control. Presumably, these interventions are based on the notion that changes in these cognitive factors are related to changes in measures of adjustment. The aim of the present study was to explore whether changes on these cognitive factors were related to changes in CLBP and disability. Fifty-four CLBP patients completed a series of self-report measures prior to beginning a cognitive-behavioral based intervention and again upon discharge. Change scores (post-treatment score minus pre-treatment score) were calculated for each of the self-report measures. The study found that changes in the cognitive factors were not significantly associated with changes in pain intensity. In contrast, reductions in fear-avoidance beliefs about work and physical activity, as well as increased perceptions of control over pain were uniquely related to reductions in disability, even after controlling for reductions in pain intensity, age and sex. The final model explained 71% of the variance in reductions in disability.     

Low levels of physical activity in back pain patients are associated with high levels of fear‐avoidance beliefs and pain catastrophizing

Background and Purpose. Fear‐avoidance beliefs are important determinants for disability in patients with non‐specific low‐back pain (LBP). The association with self‐reported level of physical activity is less known. The aim of the present study was to describe the level of physical activity in patients with chronic non‐specific LBP and its relation to fear‐avoidance beliefs and pain catastrophizing. Method. A cross‐sectional study on 64 patients with chronic non‐specific LBP in primary healthcare. The variables measured and the questionnaires used were: level of physical activity (six‐graded scale); activity limitations (Roland Morris Disability Questionnare (RDQ)); fear‐avoidance beliefs (Tampa Scale of Kinesiophobia (TSK) 13‐item and sub‐scales ‘activity avoidance’ and ‘somatic focus’); and pain catastrophizing (Pain Catastrophizing Scale (PCS)). The level of physical activity was dichotomised into low and high physical activity. Individual median scores on the TSK and PCS scales were used to group the patients into different levels of fear‐avoidance beliefs and pain catastrophizing. Univariate logistic regressions were used to calculate odds ratios for having low physical activity. Results. Patients with low physical activity had significantly higher scores in fear‐avoidance beliefs and pain catastrophizing (p < 0.05). Odds ratios for low level of physical activity were between 4 and 8 (p < 0.05) for patients with high fear‐avoidance beliefs or medium/high pain catastrophizing. Conclusions. This study indicates that it seems important for physiotherapists in primary care to measure levels of fear‐avoidance beliefs or pain catastrophizing. In particular, the two subscales of the TSK could be of real value for clinicians when making treatment decisions concerning physical exercise therapy for patients with chronic LBP. Copyright © 2007 John Wiley & Sons, Ltd.     

The relationships between measures of stature recovery, muscle activity and psychological factors in patients with chronic low back pain

Individuals with low back pain (LBP) often exhibit elevated paraspinal muscle activity compared to asymptomatic controls during static postures such as standing. This hyperactivity has been associated with a delayed rate of stature recovery in individuals with mild LBP. This study aimed to explore this association further in a more clinically relevant population of NHS patients with LBP and to investigate if relationships exist with a number of psychological factors. Forty seven patients were recruited from waiting lists for physiotherapist-led rehabilitation programmes. Paraspinal muscle activity while standing was assessed via surface electromyogram (EMG) and stature recovery over a 40-min unloading period was measured on a precision stadiometer. Self-report of pain, disability, anxiety, depression, pain-related anxiety, fear of movement, self-efficacy and catastrophising were recorded.Correlations were found between muscle activity and both pain (r = 0.48) and disability (r = 0.43). Muscle activity was also correlated with self-efficacy (r = −0.45), depression (r = 0.33), anxiety (r = 0.31), pain-related anxiety (r = 0.29) and catastrophising (r = 0.29) and was a mediator between self-efficacy and pain. Pain was a mediator in the relationship between muscle activity and disability. Stature recovery was not found to be related to pain, disability, muscle activity or any of the psychological factors. The findings confirm the importance of muscle activity within LBP, in particular as a pathway by which psychological factors may impact on clinical outcome. The mediating role of muscle activity between psychological factors and pain suggests that interventions that are able to reduce muscle tension may be of particular benefit to patients demonstrating such characteristics, which may help in the targeting of treatment for LBP.     

慢性髋关节疼痛患者的功能障碍及相关心理因素分析

目的 分析慢性髋关节疼痛患者功能障碍的特点,阐明其功能障碍与心理因素之间的关系。方法 收集2021年4月至2022年3月解放军总医院收治的55例慢性髋关节疼痛患者(患者组),34例健康受试者作为对照组。通过问卷调查采集患者一般人口学信息和临床资料。采用髋关节日常生活能力评分(HOSADL)、髋关节运动能力评分(HOS-SSS)、改良Harris髋关节评分(mHHS)、12项健康调查简表(SF-12)、视觉模拟评分(VAS)、医院焦虑抑郁量表(HADS)(分为HADS:A和HADS:D)、焦虑状态/特质问卷(STAI)、疼痛灾难化量表(PCS)、Pittsburgh睡眠质量指数(PSQI)进行评价,并分析与各项临床指标的相关性。结果 患者组mHHS、HOS-ADL、HOS-SSS、SF-12评分均显著低于对照组(|Z|> 6.251, P <0.001)。mHHS、HOS-ADL、HOS-SSS、SF-12评分均与PCS评分呈负相关(|r|> 0.480, P <0.01)。PCS的影响因素为HADS:A,HADS:D和HOS-ADL。结论 慢性髋关节疼痛患者功能...     

Role of pain catastrophizing during pain processing in a cohort of patients with chronic and severe arthritic knee pain

We examined the relationship between catastrophizing and a 3-stage model of pain processing, consisting of pain sensation intensity (stage 1), pain unpleasantness (stage 2), and suffering (stage 3). We studied 310 patients with chronic and severe osteoarthritic knee pain (68.7% female) using 4 competing structural equation models. A strong relationship was found between the suffering construct and its indicators. Of the 4 theoretically plausible models, we found a model with 3 specific pathways of pain sensation leading to the final stage of pain-related suffering. A unique contribution of this study is the integration of catastrophizing into the 3 pain stages. In this model, catastrophizing mediates the relationship between pain-related unpleasantness and suffering, as well as the relationship between sensation and suffering through unpleasantness. Psychological intervention targeting catastrophizing could provide reduction of pain-related suffering that adds to the benefits of therapies directed toward the primary sensory and immediate unpleasant dimensions of pain. These results emphasize the benefit of integrating knowledge of the psychological and neural mechanisms of pain.