The effectiveness of a functional training programme for patients with chronic low back pain – a pilot study

Introduction.?To investigate the effect of an individualised functional training programme for patients with low back pain (LBP).

Methods.?A randomised, controlled trial with single-blind design was conducted. Patients with non-specific LBP for at least 3 months were recruited and randomised into training and control groups. Both groups maintained their current treatment, and the training group participated in an additional programme for 100 h. Measures were performed initially and after completing the programme, and included rating determining impairment associated with pain, Oswestry disability index (ODI) and functional capacity evaluation (FCE).

Results.?Thirteen in the training group completed the training and measurements, and 12 in the control group completed their measurements. Twelve items in FCE had significant improvement in training group, but only one in control group. Severity of pain (11.8 ± 3.6–5.6 ± 3.6), activity limitation from pain (3.2 ± 1.5–1.5 ± 1.1) and emotional disturbance by pain (4.3 ± 1.7–2.2 ± 1.4) significantly decreased in the training group, no significant change in the control group. The ODI demonstrated a significant reduction (p = 0.044) in the training group (22 ± 9–16 ± 9), but not in the control group.

Conclusion.?An individualised functional training programme benefits chronic LBP patients.     

Instruments used to assess functional limitations in workers applying for disability benefit: a systematic review

Purpose.?To systematically review the quality of the psychometric properties of instruments for assessing functional limitations in workers applying for disability benefit.

Method.?Electronic searches of Medline, Embase, CINAHL and PsycINFO were performed to identify studies focusing on the psychometric properties of instruments used to assess functional limitations in workers' compensation claimants. Two independent reviewers applied the inclusion criteria to select relevant articles and then evaluated the psychometric qualities of the instruments found.

Results.?Of the 712 articles that were identified, 10 studies met the inclusion criteria, reporting on four instruments: the Roland–Morris Disability Questionnaire (RMDQ), the Patient-Specific Functional Scale (PSFS), the Isernhagen Work System (IWS) and the Multiperspective Multidimensional Pain Assessment Protocol (MMPAP). The questionnaires (RMDQ and PSFS) did not focus specifically on the work situation and measured three to eight functional limitations. The psychometric qualities of the IWS were poor to moderate. For the MMPAP, only predictive validity was measured. The instruments assessed a range varying between 3 and 34 physical functional limitations. No instruments were found for assessing mental limitations in workers' compensation claimants.

Conclusion.?Studies on four instruments specifically focusing on assessing physical functional limitations in workers applying for disability benefit were found. All four instruments have limitations regarding their psychometric qualities or contents. Since the RMDQ has the best demonstrated psychometric qualities and takes little time to complete it, we recommend the RMDQ for clinicians in rehabilitation. For the assessment of functional limitations in workers applying for disability benefit a combination of questionnaires, performance tests or interviews together with the judgment by physicians looks the most promising.     

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.     

Correlations between pain and function in a longitudinal low back pain cohort

Purpose.?Most studies of low back pain (LBP) and functional limitation have been cross-sectional, and show only modest correlations between pain and function. Though functional limitation may be superior for predicting disability outcomes, there is a need to understand better the gap between pain and function. This study analysed changes in intra-individual correlations between pain and function over time.

Method.?Seventeen men and 16 women currently experiencing LBP provided self-reports of LBP (0-to-10 scale) and functional status (Back Pain Functional Scale) for a maximum of 8 weeks. Spearman correlation coefficients between pain and function scores were calculated for each individual. The effects of pain history, pain intensity, variability and trends over time on pain–function correlations were assessed.

Results.?There were no significant differences in correlation due to gender, age or pain intensity (low versus high). Participants with steeper slopes in change in pain score over the study period had significantly stronger correlations to function than those with weaker trends, r?==??0.91 and r?==??0.45, respectively. Participants with at least one pain-free score during the reporting period had significantly stronger correlations than those with no pain-free reports, r?==??0.80 and r?==??0.51, respectively. Participants having the first episode LBP had stronger correlations (r?==??0.85) than those with persistent symptoms of LBP (r?==??0.62).

Conclusions.?The results suggest that over the course of LBP, within-person pain–function correlations are stronger than those reported in cross-sectional, population-based studies. Changes in pain ratings over time may have more clinical relevance than differences in pain levels between individuals. Among those with more long-standing pain, factors other than pain intensity, such as pain catastrophising or fear avoidant beliefs, may have a greater effect on day-to-day perceptions of functional limitation.     

Managing pain in the workplace: a focus group study of challenges,strategies and what matters most to workers with low back pain

Purpose.?Most working adults with low back pain (LBP) continue to work despite pain, but few studies have assessed self-management strategies in this at-work population. The purpose of this study was to identify workplace challenges and self-management strategies reported by workers remaining at work despite recurrent or persistent LBP, to be used as a framework for the development of a workplace group intervention to prevent back disability.

Method.?Workers with LBP (n?=?38) participated in five focus groups, and audio recordings of sessions were analysed to assemble lists of common challenges and coping strategies. A separate analysis provided a general categorisation of major themes.

Results.?Workplace pain challenges fell within four domains: activity interference, negative self-perceptions, interpersonal challenges and inflexibility of work. Self-management strategies consisted of modifying work activities and routines, reducing pain symptoms, using cognitive strategies and communicating pain effectively. Theme extraction identified six predominant themes: knowing your work setting, talking about pain, being prepared for a bad day, thoughts and emotions, keeping moving and finding leeway.

Conclusions.?To retain workers with LBP, this qualitative investigation suggests future intervention efforts should focus on worker communication and cognitions related to pain, pacing of work and employer efforts to provide leeway for altered job routines.     

Effectiveness of workplace rehabilitation interventions in the treatment of work-related low back pain: A systematic review

Purpose.?A systematic review was conducted to evaluate the effectiveness of workplace rehabilitation interventions for injured workers with low back pain (LBP).

Method.?MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and AMED (Allied and Complementary Medicine) were searched from 1982 to 2005 for peer-reviewed studies of rehabilitation interventions that were provided at the workplace to workers with musculoskeletal work-related LBP. Methodological quality appraisal and data extraction were conducted by five reviewers.

Results.?Of a total of 1,224 articles that were identified by the search, 15 articles, consisting of 10 studies, were of sufficient quality to be included in the review. The best evidence was that clinical interventions with occupational interventions as well as early return to work/modified work interventions were effective in returning workers to work faster, reducing pain and disability, and decreasing the rate of back injuries. Ergonomic interventions also were found to be effective workplace interventions.

Conclusion.?The need for further research in this area is necessary to reduce the burden of back pain on employees and their families, employers, and the health care system.     

The relationship between work function and low back pain history in occupationally active individuals

Purpose.?To investigate the relationship between work function and low back pain (LBP) history.

Study design.?Cross-sectional study.

Background.?In some countries, traditional medical examinations do not assess work performance in people who continue working despite a history of LBP, although such assessment may be required.

Methods.?A total of 100 industrial metal workers were assigned to groups with and without LBP history. Logistic regression and t-tests examined the associations between physical work performance (represented by dynamic strength evaluation) and the group, and compared worker performance between the two groups. Similar tests examined potentially confounding effects on group assignment.

Results.?Work performance was significantly associated with the group in dynamic strength sub-tests assessing weight lifting and carrying. The weights handled were lower in the group with LBP history (p < 0.05). Only the workers' country of origin affected group assignment; adjustment for this factor, as well as for age and education improved the associations between work performance and the group.

Conclusions.?Workers with a history of LBP display decreased physical performance at work, which should be subject to further research and treated as a health-related problem in accordance with the ICF model.     

Are localized low back pain and generalized back pain similar entities? Results of a longitudinal community based study

Purpose.?To compare subjects with localized low back pain (LBP) and with generalized back pain (BP) with regard to baseline characteristics and long-term outcomes.

Methods.?A community-based longitudinal study. All inhabitants aged 22 – 70 of a single town were asked to complete self-administered questionnaires regarding back and neck pain and lifestyle characteristics. Those reporting LBP during the previous month were followed up after one year. Data were stratified by sites of pain with respect to ‘localized LBP’ and to ‘LBP with additional sites of BP’. Among LBP measures were the Roland and Morris Disability scale and Pain symptoms indices.

Results.?Nearly 30% of the total population (602) experienced LBP during the previous month, of whom more than half (336) reported ‘localized LBP’ and the rest LBP + neck and or upper back pain (Generalized BP). Both subgroups differed from those free of BP, however, those reported ‘Generalized BP’ comprised more females, were less educated, smoked more, were less engaged in sporting activities and reported higher level of LBP measures than those reported ‘localized LBP’. After one year, both subgroups were similar with regard to lifestyle but remained different with regard to some of the LBP measures.

Conclusions.?Subjects with ‘localized LBP’ presented healthier lifestyle than subjects with ‘Generalized BP’. The latter experienced higher degree of pain measures. It seems that ‘Generalized BP’ is not a different entity than ‘localized LBP’ but rather a more severe one.     

The association between cognitive factors,pain and disability in patients with idiopathic chronic neck pain

Purpose.?The aim of this study was to establish the relationship between known cognitive factors and levels of pain and disability in patients with idiopathic chronic neck pain.

Method.?Ninety-four patients referred for physiotherapy because of chronic neck pain completed measures of pain, disability, catastrophising, pain-related fear, pain vigilance and awareness and self-efficacy beliefs. Hierarchical multiple regression analyses were then performed to establish whether the cognitive factors were significant determinants of levels of pain and disability.

Results.?The cognitive measures were significantly related to levels of pain and disability, explaining 23% of the variance in pain intensity and 30% of the variance in disability. Specifically, greater catastrophising (β?=?0.37, p?<?0.05) and lower pain vigilance and awareness (β?=???0.32, p?<?0.05) were associated with greater pain intensity. Moreover, greater catastrophising (β?=?0.26, p?<?0.05) and lower functional self-efficacy beliefs (β?=???0.34, p?<?0.001) were significantly associated with greater levels of disability.

Conclusions.?Cognitive factors were strongly related to levels of pain and disability in patients with chronic neck pain. In view of this, targeting the modification of these cognitive factors should be an integral part of therapy when treating patients with idiopathic chronic neck pain.     

A new episode of low back pain: Who relies on bed rest?

Bed rest has been shown to be an ineffective treatment for non‐specific low back pain (LBP). Despite this, during a new episode of pain some patients still rely on bed rest. Which patients choose bed rest is however unknown. The objectives of the present study were, firstly, to assess characteristics of patients choosing bed rest in (sub)acute pain and secondly to study whether prolonged bed rest in the (sub)acute phase of pain will result in long term disability. A prospective longitudinal cohort study included 282 patients with non‐specific LBP for less than 7 weeks. Main outcome measures were duration of bed rest (in three categories) and disability. Results showed that 33% of patients with (sub)acute LBP had bed rest, but only 8% stayed in bed for more than four days. An ordinal regression analysis revealed that behavioural factors (catastrophizing (OR=1.05 per bed rest category p<0.01)) and fear of injury (OR=1.05 per category p<0.01) rather than specific pain related factors (pain history (OR=0.61 per category p=0.16) and pain intensity (OR=1.00 per category p=0.63)) were associated with bed rest. Patients with prolonged bed rest in an early phase of pain were still more disabled after one year (p<0.01). Based on these results we conclude that prolonged bed rest in the early phase of pain is associated with a higher long term disability level. In preventing low back disability, GP screening for catastrophizing and fear of injury in LBP patients who had prolonged bed rest merits consideration.     

Validation of the NHANES ADL scale in a sample of patients with report of cervical pain: Factor analysis,item response theory analysis,and line item validity

Background.?Few functional outcomes scales have used Item Response Theory (IRT) for validation. IRT allows individual line item validations and offers substantial advantages over classic methods of scale validation or the simplest from of IRT known as Rasch. Rasch analysis reduces data to dichotomous variables thus decreasing the sensitivity of Likert-type data responses.

Purpose.?The purpose of this study was to create an outcome scale associated with the latent trait of functioning and disability, validated using IRT, in a population with report of cervical pain.

Methods.?Using the NHANES database, a recently created scale (NHANES ADL scale) was analysed using factor analysis, internal analyses of consistency, IRT, and comparison with internal measures of functioning and disability.

Results.?The newly created NHANES ADL scale demonstrated uni-dimensionality, was internally reliable, and was correlated to internal measures of functioning and disability. Additionally, the majority of the scale items demonstrate strong discrimination and suitable thresholds.

Discussion.?The NHANES ADL scale effectively measures physical, social, and emotional disability in patients with a cervical impairment, and may be an efficient measure of perceived limitations from working and generalized daily physical activity.

Conclusion.?The newly created NHANES ADL scale demonstrates internal consistency, unidimensionality, and line item validity. The NHANES ADL scale appears to be a useful instrument in measurement of functioning and disability in patients with report of cervical pain.     

Predictors of functional disability in rheumatoid arthritis: Results from a 13-year prospective study

Purpose.?To explore the role of distress and social support as modifiers of functional disability in rheumatoid arthritis (RA). We hypothesized that: (a) higher inflammatory activity, more joint tenderness and more pain lead to more disability, and (b) that more distress and less social support lead to more disability and accelerate the disablement process by moderating the effects of inflammatory activity, joint tenderness and pain.

Methods.?The study is a Dutch extension of the European Research on Incapacitating Diseases and Social Support (EURIDISS) which started with 292 patients. After five waves of data collection 129 still participated. Correlational and hierarchical regression analyses were performed.

Results.?In short-term RA, 68% of the variance in disability could be explained primarily by mean disability over the prior years. Other important predictors were inflammatory activity and pain. In long-term RA, 56% of the variance in disability could be explained primarily by mean disability over the prior years. Other important predictors were joint tenderness and pain. No clear moderator effects of distress and social support were found in short-term or long-term RA.

Conclusions.?The results confirm the main pathway from pathology to disability in short-term and long-term RA, but do not provide support for the influence of distress and social support on the disablement process.     

Quality of life and maintenance of improvements after early multimodal rehabilitation: A 5-year follow-up

Purpose.?There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up.

Method.?The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status.

Results.?Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation.

Conclusions.?These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.     

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.     

Life dissatisfaction in the pre-operative and early recovery phase predicts low functional ability and coping among post-operative patients with lumbar spinal stenosis: a 2-year prospective study

Purpose.?We examined the significance of life dissatisfaction in pre-operative and early recovery phases with respect to functional ability, pain and coping on 2-year follow-up of patients with lumbar spinal stenosis (LSS).

Methods.?Patients (n?=?90, mean age, 62 years, men 40%) with symptomatic LSS underwent decompressive surgery. Data collection took place with the same set of questionnaires before surgery and 3 months, 6 months and 2 years postoperatively. Life dissatisfaction was assessed with the four-item life satisfaction (LS) scale. In addition, a life dissatisfaction burden, comprising the sum of preoperative, 3-month and 6-month LS scores, was calculated. Physical functioning (Oswestry disability index), pain (VAS and pain drawing) and coping (sense of coherence, SOC) were assessed. Logistic regression analysis was used to examine life dissatisfaction as a predictor of the 2-year functional ability, pain and coping (SOC).

Results.?In these analyses, pain was not predicted by either pre-operative life dissatisfaction or life dissatisfaction burden. However, both disability and poor coping on 2-year follow-up were independently associated with both pre-operative and early recovery phase life dissatisfaction.

Conclusions.?Our results show the importance of both pre-operative and early post-operative well-being regarding subsequent functioning. Thus, monitoring of the subjective well-being throughout the pre-operative and post-operative period may indicate those patients at risk of poorer post-operative recovery.     

A bio-psycho-social approach for treating sub-acute low back pain

Purpose.?This article examines the distinctive opportunities and challenges involved in treating sub-acute low back pain (LBP). Several risk factors have been identified. Thus, a multi-disciplinary design and a comprehensive bio-psycho-social approach seem to be the best modality of intervention to improve outcome.

Method.?The relevant literature on various factors that are supposed to improve outcome is summarised and discussed.

Results.?A controversial on the rehabilitation benefits still exists. From one side, meta-analytic studies provide a small evidence of effectiveness. Most treatments for chronic LBP provide weak results and the benefits can be just transient. From the other side, comprehensive bio-psycho-social approaches seem to be the best modality of intervention to facilitate physical outcome and return to work.

Conclusion.?This article reflects the conviction that clinicians with a special knowledge on LBP problems and researchers with a special knowledge on health policy will better work together. Their targets are outcome and cost-benefit ratio by taking into account the economical and political milieu of the country where the research is carried out.     

Self-reported activity in tortured refugees with long-term sequelae including pain and the impact of foot pain from falanga – a cross-sectional study

Purpose.?To describe activity limitations in tortured refugees referred for rehabilitation, particularly the impact of neuropathic pain resulting from falanga (beatings under the feet).

Methods.?Physiotherapists assessed 103 consecutively referred torture victims with a long history of sequelae, among them pain and mobility problems. All had been subjected to various forms of physical and psychological torture and 71 victims had also suffered falanga. Main outcome measures used were: the Disability Rating Index (DRI; 12 items) to assess self-reported capacity to carry out daily activities; for falanga victims, a specific foot assessment of sensory function in the feet.

Results.?All patients perceived clear activity limitations according to the DRI. The falanga victims' feet were categorised according to the type of foot pain: stimulus-independent pain; stimulus-evoked pain; no pain. The two groups with foot pain displayed sensory dysfunction and suffered more extensive activity limitations. After correction for confounding factors, these two groups reported significantly more activity limitations in 7 out of 12 DRI items than those who were not exposed to falanga.

Conclusion.?In this group of victims who had chronic pain for at least 5 years after torture, all perceived activity limitations, but pain from falanga had a greater overall impact on disability assessed in terms of daily activities.     

Depressive symptoms predict postoperative disability among patients with lumbar spinal stenosis: A two-year prospective study comparing two age groups

Purpose.?To examine the importance of preoperative and recovery phase depressive symptoms in two age groups of patients with lumbar spinal stenosis (LSS) with respect to surgery outcome 2 years postoperatively.

Method.?Ninety-six patients with symptomatic LSS underwent decompressive surgery. Data were collected with self-report questionnaires before surgery and 3 months, 6 months, 1 year and 2 years postoperatively. Depression was assessed with the Beck Depression Inventory (BDI). Depressive burden was examined by compiling the sum of preoperative, 3-month and 6-month BDI scores. Physical functioning and pain were assessed with the Oswestry Disability Index, Walking ability and VAS. In the analyses, the subjects were divided into two groups according to the median age (62 years).

Results.?Depressive burden was a strong predictor of disability at the 2-year postoperative phase both in younger and elderly patients with LSS. A notable proportion (20%) of the younger patients had considerable depressive symptomatology 2 years after the surgery, whereas in the older age group this proportion was 8%.

Conclusion.?The results suggest that there is a strong relationship between depressive symptoms and disability among postoperative patients with LSS. Identifying and treating patients with preoperative and postoperative depressive symptoms may be a useful strategy for improving LSS surgery outcomes.