The patient–physician relationship in patients with chronic low back pain as a predictor of outcomes after rehabilitation

For patients with chronic diseases, especially those with chronic low back pain, the patient–physician relationship is significant for treatment adherence. In a sample of N = 688 low back pain patients, we examined the hypothesis that aspects of the patient–physician relationship (e.g. satisfaction with care, trust in the physician, patient participation) have a significant association with outcomes (pain, disability, quality of life, pain-related psychological impairment) after a multimodal treatment program (rehabilitation) after adjusting for a number of sociodemographic, medical, and psychological factors. Results show that the patient–physician relationship is significantly associated with the outcome. In the medium term (6 months after rehabilitation), the effect of the patient–physician relationship is clearer than in the short term (end of rehabilitation). In addition, risk factors for less improvement are female gender, higher age, low income, comorbidity, low treatment motivation, fear avoidance beliefs, and external locus of control. Future studies should examine the causal paths between the relationship variables and the outcome variables.     

Assessing pain and pain-related fear in acute low back pain: what is the smallest detectable change?

Background: The Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire (FABQ) are frequently used questionnaires for pain-related fear, and the visual analogue scale (VAS) is for pain. Purpose: This study aims to determine the smallest detectable change (SDC) of these questionnaires in patients with acute low back pain (LBP), as well as ceiling and/or floor effects. Results: The SDC for the TSK (scoring range: 17–68) was 9.2 (95% CI: 8.4; 10.3). The estimated SDC was 9.4 (95% CI: 8.5; 10.6) and 12.7 (95% CI: 11.5; 14.1) for the FABQphysical activity subscale (scoring range: 0–24) and/or work subscale (scoring range: 0–42), respectively. For the VAS for pain (0–100 mm), the SDC turned out to be 36.2 mm (95% CI: 32.4; 41.0). The FABQ physical activity subscale and pain (VAS) seem to have considerable problems in detecting improvement and deterioration. The TSK appears to be able to detect improvement as well as deterioration. Conclusion: The SDCs of the (subscales of) questionnaires range from 18% to 40%. Floor and/or ceiling effects were detected for most scales, except the TSK total and the TSK activity avoidance subscale. These results should be considered when using these questionnaires as measures of therapeutic change in acute LBP.     

Complementary and alternative medical therapies for chronic low back pain: What treatments are patients willing to try?

Background  

Although back pain is the most common reason patients use complementary and alternative medical (CAM) therapies, little is known about the willingness of primary care back pain patients to try these therapies. As part of an effort to refine recruitment strategies for clinical trials, we sought to determine if back pain patients are willing to try acupuncture, chiropractic, massage, meditation, and t'ai chi and to learn about their knowledge of, experience with, and perceptions about each of these therapies.     

Low back muscle fatigue during Sørensen endurance test in patients with chronic low back pain: relationship between electromyographic spectral compression and anthropometric characteristics

This study assessed low back muscle fatigue during S?rensen back endurance test in chronic low back pain (CLBP) patients and healthy controls, and investigated relationship between the erector spinae muscle fatigability and subject's anthropometric characteristics. Four groups (n = 10 per group) of middle-aged (47-52-year-old) subjects participated: 1) female CLBP patients, 2) healthy female subjects, 3) male CLBP patients and 4) healthy male subjects. Subjects performed S?rensen back endurance test until exhaustion, while electromyographic (EMG) power spectrum median frequency compression over time (MF slope) as indicator of the erector spinae muscle fatigability, and endurance time were recorded. The endurance time was shorter (p < 0.05) in male CLBP patients compared to the healthy male and female subjects. No significant gender differences in endurance time were found in CLBP patients and in healthy subjects. EMG power spectrum MF slope did not differ significantly in CLBP patients and in healthy subjects. However, MF slope was higher (p < 0.05) in healthy male than in female subjects. Body mass and BMI correlated moderately positively with MF slope (r = 0.40-0.67) in all measured groups. We conclude that male CLBP patients had lower back extensor muscle isometric endurance compared to the healthy subjects of both genders, whereas no gender differences in isometric endurance were found in CLBP patients and in healthy subjects. Healthy male subjects had greater lumbar erector spinae muscle fatigability compared to the healthy female subjects. Subjects with higher body mass and body mass index fatigued faster during S?rensen back endurance test.     

What does pain signify? A hypothesis concerning pain, the immune system and unconscious pain experience under general anesthesia

In this paper, I present a case-study that initiates a discussion about the meaning of pain. The case-study concerns a person who was under deep sedation during colonoscopy. The person did not experience pain from a first-person perspective, although pain was evident to the medical team from a second-person perspective. The divergence of pain perspectives raises an interesting quandary. If the body communicates pain while pain consciousness is blocked by the sedation procedure, our conclusion should be that the intersubjective aspect of pain precedes the "subjective," first-person experience of pain. This conclusion is not consistent with the common representational conception of pain that places the intrasubjective point of view prior to the intersubjective point of view. The solution I offer to this quandary is the quasi-paradoxical idea that pain can be experienced unconsciously through the immune system. Following this suggestion, I hypothesize that post-traumatic stress disorders following general anesthesia may result from this unconscious pain experience. If this idea is scientifically grounded, then physicians should: (1) consider ways of blocking the unconscious pain experience produced by the immune system without interfering with the immune response, and (2) study pain as a complex cognitive and unconscious system by drawing an analogy with the immune system, which follows similar logic.     

Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis

Background

Chronic pain and its associated distress and disability are common reasons for seeking medical help. Patients with chronic pain use primary healthcare services five times more than the rest of the population. Mindfulness has become an increasingly popular self-management technique.

Aim

To assess the effectiveness of mindfulness-based interventions for patients with chronic pain.

Design and setting

Systematic review and meta-analysis including randomised controlled trials of mindfulness-based interventions for chronic pain. There was no restriction to study site or setting.

Method

The databases MEDLINE^®, Embase, AMED, CINAHL, PsycINFO, and Index to Theses were searched. Titles, abstracts, and full texts were screened iteratively against inclusion criteria of: randomised controlled trials of mindfulness-based intervention; patients with non-malignant chronic pain; and economic, clinical, or humanistic outcome reported. Included studies were assessed with the Yates Quality Rating Scale. Meta-analysis was conducted.

Results

Eleven studies were included. Chronic pain conditions included: fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, failed back surgery syndrome, and mixed aetiology. Papers were of mixed methodological quality. Main outcomes reported were pain intensity, depression, physical functioning, quality of life, pain acceptance, and mindfulness. Economic outcomes were rarely reported. Meta-analysis effect sizes for clinical outcomes ranged from 0.12 (95% confidence interval [CI] = −0.05 to 0.30) (depression) to 1.32 (95% CI = −1.19 to 3.82) (sleep quality), and for humanistic outcomes 0.03 (95% CI = −0.66 to 0.72) (mindfulness) to 1.58 (95% CI = −0.57 to 3.74) (pain acceptance). Studies with active, compared with inactive, control groups showed smaller effects.

Conclusion

There is limited evidence for effectiveness of mindfulness-based interventions for patients with chronic pain. Better-quality studies are required.     

Affective modulation of the acoustic startle: does sadness engage the defensive system?

It has been suggested that high arousal negative affective states, but not low arousal negative affective states, potentiate the startle response. Because sadness has generally been studied as a low arousal emotion, it remains unclear whether high arousal sadness would produce startle potentiation to a similar degree as high arousal fear. To address this issue, 32 participants viewed two sets of 10-min film clips selected to induce two affective states of high subjective arousal (fear, sadness) and a neutral state of low subjective arousal, while the eyeblink startle response associated with brief noise bursts was assessed using orbicularis oculi EMG. Larger blink magnitude was found for fearful than for sad or neutral clips. Implications for conceptualizing sadness are discussed.     

Self-management support needs of patients with chronic illness: Do needs for support differ according to the course of illness?

Objective

To determine whether chronically ill patients’ needs for self-management support depend on their course of illness.

Methods

Cross-sectional and longitudinal linear regression analyses were conducted using data from 1300 patients with chronic disease(s) who participated in a nationwide Dutch panel-study. Self-management support needs were assessed by the Patient Assessment of Self-management Tasks questionnaire (PAST). Course of illness was operationalized as: illness duration, patients’ perception of the course of illness and changes in self-rated general health (RAND-36).

Results

Self-management support needs are not related to illness duration. Patients who perceive their illness as episodic and/or progressively deteriorating have greater self-management support needs than patients who perceive their illness as stable. Deterioration of self-rated health is related to increased support needs. The effect of the course of illness on support needs depends on the type of self-management activities.

Conclusion

How chronically ill patients perceive the course of illness and actual changes in self-rated health are predictive for their need for support for self-management activities. Illness duration is not.

Practice implications

Helping patients to self-manage should not be confined to the first years after diagnosis. Healthcare providers should be alert to patients’ own perceptions of their course of illness and health status.     

Are living beings in the state of self-organized criticality? A new interpretation of data on work incapacity due to low back pain

Using data published elsewhere I demonstrate in this paper that the frequency distribution of the duration of work incapacity from low back pain follows a power law. Power laws are not common in medicine and the question arises why we can find one here. The peculiarity of the data considered here is that they embrace not only the passive reaction but also the whole spectrum of possible active responses of a living being to a disturbance. For the duration of sick leave due to low back pain is not only influenced by the defect a person is affected by, but even more dependent on how he or she copes with it. Coping comprises a broad range of possibilities from denial of the disability to its aggravation, from therapy to malingering. In contrast to the scientific ideal none of these faculties has been excluded in the data used here. They concern the whole living being. Power laws are typical for systems in the state of self-organized criticality. The system involved in the case of low back pain is the whole living human being with all its possibilities to react and to respond. Thus, my findings support empirically the hypothesis that living beings are in the state of self-organized criticality.     

Asymmetrical movements of the lumbopelvic region: Is this a potential mechanism for low back pain in people with lower limb amputation?

Low back pain (LBP) is a major secondary disabling condition following lower limb amputation including persons with above-knee and below-knee amputation. Whilst the increasing prevalence of this musculoskeletal problem in people with lower limb amputation is well recognised, the mechanisms of LBP in this population have been poorly explored. Asymmetrical movements and loading patterns have been found in persons following lower limb amputation and linked to the high prevalence of LBP in this population. However, some argue that such asymmetries are part of the ‘normal’ adaptive process following lower limb amputation. We hypothesise that there is potential for some of the kinematic and kinetic adaptations in the lumbopelvic and trunk region to be ‘mal-adaptive’, potentially acting as a contributing factor for the onset or maintenance of LBP symptoms in this population. Evidence for movement and muscle asymmetries around the lumbopelvic and lower limb region provides some support for an association between LBP and movement asymmetry in the general population. It is therefore reasonable to hypothesise that movement asymmetries will demonstrate an association with LBP in lower limb amputee populations. Previous studies investigating movement and loading patterns within this population have focused mainly on gait analysis. Therefore, there is a need for further research to investigate the presence and potential association of asymmetrical movement patterns of the lumbopelvic region with LBP in a range of specific functional tasks. Results of such studies will identify the asymmetrical movement patterns and functional tasks associated with LBP in this population. Furthermore, it will inform future case-control and longitudinal studies to specifically investigate the putative links for such asymmetrical movement patterns as risk factors to LBP in this population.     

Occupational and nonoccupational risk indicators for incident and chronic low back pain in a sample of the swedish general population during a 4-year period: An influence of depression?

The objectives of this study were to examine the relation between occupational and nonoccupational conditions and both incident (IBLP) and chronic low back pain (CLBP), aswellasdepression, among women and men. Data from a4-year follow-up of a study group consisting of 420 participants of both genders from the general Swedish population were analysed. Occupational risk indicators were predictors for both ILBP and CLBP. Depression was not found to be a predictor for either IBLP or CLBP among women, but was a predictor for CLBP among men. Among women, depression had some risk indicators in common with ILBP and appeared to be a concurrent outcome rather than a risk indicator. Low back pain in 1993 was not a predictor for depression in 1997 in either women or men. Occupational conditions are of relevance in relation to both incident and CLBP. Nonoccupational conditions were stronger predictors for CLBP than for ILBP but had some predictive value also for ILBP.     

Fit for purpose? Using the fit note with patients with chronic pain: a qualitative study

Background

Staying in work may benefit patients with chronic pain, but can be difficult for GPs to negotiate with patients and their employers. The new fit note is designed to help this process, but little is known of how it is operating.

Aim

To explore GPs'' views on the fit note, with particular reference to sickness certification for patients with chronic pain.

Design and setting

Qualitative study using semi-structured interviews in eight primary care trusts in south-west England.

Method

In-depth interviews with 13 GPs.

Results

GPs reported that the rationale behind the fit note is sound and that it may help patients with chronic pain to return to work earlier. However, GPs also reported barriers to successful fit note use, including the need to preserve doctor–patient relationships, inconsistent engagement from employers, GPs'' lack of specialist occupational health knowledge, issues with fit note training, and whether a new form can achieve cultural shift.

Conclusion

While doctors agree that good work improves health outcomes, they do not think that fit notes will greatly alter sickness-certification rates without more concerted initiatives to manage the tripartite negotiation between doctor, patient, and employer.     

Self-mutilation in the Lesch-Nyhan syndrome: a corporalconsciousness problem? —a new hypothesis

The Lesch-Nyhan syndrome (LNS) has been extensively studied from the genetic and biochemical point of view. The main characteristic of the syndrome is the self-mutilation feature, which has been poorly studied and understood. We propose a new hypothesis about the self-mutilation physiopathology, which is related to the supersensitivity of the dopaminergic D1 receptors in the neuromatrix found in the cingulum cortex region.The LNS shows an increase of uric acid levels as a result of the deficiency of hypoxanthine phosphoribosyltransferase enzyme. This increase could induce damage to dopaminergic neurons. As a consequence, a decrease in dopamine synthesis during gestation and the early postnatal period could occur, producing a functional dopaminergic denervation of the 131 receptors, located on the prefrontal cortex, specifically in the cingulum bundle projections. This phenomenon could induce a codification disturbance in the ‘genetic body’ of the neuromatrix, that could be expressed functionally as anosognosia, giving rise to self-mutilation. We suggest that this self-mutilation is a pain consciousness problem.