Do people with an ileostomy have a different back pain experience to those with a colostomy? A postal survey in Northern Ireland

Background.?The abdominal muscles play a vital role in lumbar stability. The stoma surgery creates a permanent flaw in the abdominal wall and this may increase the risk of low back pain for people with a stoma.

Purpose.?To determine whether there was a difference in back pain experience between the two stoma groups: ileostomy and colostomy.

Method.?A postal questionnaire sent to people in Northern Ireland with an ileostomy or colostomy.

Results.?Over half (56.7%, n?=?417) had back pain in the last 6 months and the primary perceived cause was the stoma surgery. There was a statistically significant deterioration in functional activities in those with back pain when ‘today’ was compared with ‘before surgery’. Those with a colostomy had generally poorer outcomes in respect of pain and disability, than those with an ileostomy.

Conclusion.?Low back pain in people with a stoma is a real and complex issue, especially as there are significant differences between those with an ileostomy when compared with people with a colostomy. Many factors are likely to contribute to a person developing low back pain, not least, the underlying reason for the surgery and the surgical procedure itself.     

Dynamic training of the lumbar musculature to prevent recurrence of acute low back pain: a randomized controlled trial using a daily pain recall for 1 year

Purpose: The purpose of this experiment was to quantify lumbar muscle endurance training for individuals with a recent episode of acute low back pain (LBP) (≥ moderate pain for ≥ 2 days) and to observe whether the training would reduce the rate and severity of recurrent LBP episodes. Method: Twenty-six participants who were pain-free at the time of the study were randomly divided into a high intensity back endurance (HIBE)-trained or a low intensity abdominal (LOAB)-trained (control) group. The HIBE-trained group performed preloaded maximum isokinetic exertions of the back extensors (five sets of 10 repetitions, 3 days a week for 4 weeks, totaling 12 sessions). The LOAB-trained group performed low intensity isometric contractions on their abdominals that had minimal effect on their back musculature. The two groups reported daily pain logs on a weekly basis on an interactive voice response telephone system for 1 year. Results: The HIBE-trained group experienced more pain days (p = 0.038) in the minor and moderate categories and more episodes of acute LBP than the LOAB-trained group. However, there was a trend of less pain in the severe, intense and excruciating categories in the HIBE-trained group. Conclusions: The results of this experiment did not provide evidence that short-term intense training of the low back musculature provides protection against future episodes of LBP.

Implications for Rehabilitation

• Short-term high intensity back endurance (HIBE) training of the back musculature did not provide protection against future episodes of acute low back pain compared to the low intensity abdominal (LOAB) – trained group.

• HIBE training may have sensitized the subjects to report significantly more minor and moderate pain and less pain-free days compared to the LOAB-trained group.

• There was a strong trend that the HIBE-trained group experienced less pain in the severe, intense and excruciating categories compared to the LOAB-trained group.

• Future studies in rehabilitation must require daily recall of pain and quick reporting in order to capture the subtle effects training can elicit from pain reporting.

     

Physical functioning of low back pain patients: perceived physical functioning and functional capacity,but not physical activity is affected

Abstract

Purpose: Physical functioning is a multidimensional construct covering perceived functioning, functional capacity and actual physical activity. Currently, the assessment of physical functioning in low back pain (LBP) patients has been limited to only one or two of these aspects. This study evaluates physical functioning of LBP patients by assessing the three individual aspects using questionnaires and ambulant sensor-based measurements. Methods: Actual physical activity, functional capacity and perceived functioning were measured in 26 patients undergoing patient specific treatment before, direct and 3–4 weeks after the first treatment using, respectively, sensor-based activity monitoring, sensor-based motion analysis test and the Oswestry questionnaire. Patients were compared to a healthy control group. Results: Perceived functioning and functional capacity, but not actual physical activity is impaired in pre-treatment LBP patients. After treatment, patients improved in perceived physical functioning and functional capacity approaching healthy levels, however only slight (p?>?0.05) improvements in actual physical activity were found. Moreover, only few and weak correlations were found between the different aspects of physical functioning. Conclusion: Perceived functioning, actual physical activity and functional capacity are three independent outcome dimensions, being complementary but not redundant. Especially, perceived functioning and physical capacity need attention when evaluating LBP patients during rehabilitation.

• Implications for Rehabilitation

• Perceived physical functioning and physical capacity are negatively affected by low back pain and improve after treatment.

• Low back pain patients perform their daily activity independent of pain and complaints.

• Inertia sensor-based motion analysis can objectify treatment effects showing low back pain patients their progress in rehabilitation.

• New interventions can be justified with inertia sensor technology in low back pain patients.

     

Healing of painful intervertebral discs: implications for physiotherapy

Abstract

Background: Population studies show close associations between intervertebral disc degeneration and back pain, with structural changes such as annulus tears being most closely related to pain. However, little effort has been made to link back pain to disc injury in individual patients, or to treat the disc injury in a similar way to a ligament or tendon sprain.

Objectives: To re-interpret the scientific literature in order to provide a rationale for physical therapy treatments that aim to promote ‘disc healing’.

Major Findings: Intervertebral discs deteriorate over many years, from the nucleus outwards, to an extent that is influenced by genetic inheritance, metabolite transport, and mechanical loading. Additionally, surgically-removed ‘painful’ human discs usually show an active inflammatory process proceeding from the outside-in. There is growing evidence that the ligamentous outer annulus can be re-innervated, and sensitized to pain by inflammatory-like responses to injury, and from displaced nucleus pulposus. Animal studies confirm that effective disc healing occurs only in the outer annulus and endplate, where cell density and metabolite transport are greatest. Identifying discogenic pain is not easy, but techniques are available. Healing of the disc periphery has the potential to relieve pain, by reducing inflammation and restoring function.

Conclusion: Physical therapies should aim to promote healing in the disc periphery, by stimulating cells, boosting metabolite transport, discouraging adhesion formation, and preventing re-injury. Such an approach, which can be applied through information sessions and classes, has the potential to bring about pain relief to large numbers of back pain sufferers through self-treatment.     

Work Motivating Factors in Rehabilitation: A Brief Review

Abstract

Background: Back pain is a common condition for which chiropractic treatment is often recommended.

Aim: To evaluate critically the evidence for or against the effectiveness of chiropractic spinal manipulation for back pain.

Data sources: Five independent literature searches were carried out and bibliographies were searched.

Study selection: Only randomised clinical trials of chiropractic spinal manipulation with patients suffering from back pain were included.

Data extraction: The authors extracted data on trial design, methodological quality, sample size, patient characteristics, nature of intervention, outcome measures, follow-up and results.

Main results: Twelve studies could be included. They related to all forms of back pain. Many trials had significant methodological shortcomings. Some degree of superiority of chiropractic spinal manipulation over control interventions was noted in 5 studies. More recent trials and those with adequate follow-up periods tended to be negative.

Conclusions: The effectiveness of chiropractic spinal manipulation is not supported by compelling evidence from the majority of randomised clinical trials.     

Recurrence of radicular pain or back pain after nonsurgical treatment of symptomatic lumbar disk herniation

Suri P, Rainville J, Hunter DJ, Li L, Katz JN. Recurrence of radicular pain or back pain after nonsurgical treatment of symptomatic lumbar disk herniation.ObjectivesTo determine recurrence rates of lower-extremity radicular pain after nonsurgical treatment of acute symptomatic lumbar disk herniation (LDH), and to identify predictors of recurrence.DesignProspective inception cohort.SettingOutpatient spine clinic.ParticipantsPatients (N=79) reporting resolution of radicular pain after magnetic resonance imaging confirmation of LDH.InterventionsIndividualized nonsurgical treatment tailored to the patient. All patients received education, but other treatments varied depending on the individual.Main Outcome MeasuresResolution of radicular pain was defined as a pain-free period of ≥1 month. Patients who reported resolution of radicular pain within 1 year after seeking care for acute LDH were asked whether pain had recurred at 1 year after seeking care and were also reassessed 1 year after the time of resolution of radicular pain and 2 years after seeking care. Patients reported on recurrence and the date of recurrence, if any. We evaluated the 1-year incidence of recurrence, using Kaplan-Meier survival plots. We examined predictors of recurrence using bivariate and multivariate Cox proportional hazards models. We examined the secondary outcome of back pain recurrence using identical methods.ResultsTwenty-five percent (95% confidence interval [CI], 15–35) of individuals with resolution of radicular pain for at least 1 month reported subsequent recurrence of pain within 1 year after resolution. The only factor independently associated with radicular pain recurrence was the number of months prior to resolution of pain (hazard ratio per month=1.24; 95% CI, 1.13–1.37; P<.001). The 1-year incidence of back pain recurrence was 43% (95% CI, 30–56), and older age decreased the hazard of recurrence.ConclusionsRecurrence of radicular pain is relatively common after nonsurgical treatment of LDH and is predicted by longer time to initial resolution of pain.     

Imaging of disk disease and degenerative spondylosis of the lumbar spine

Low back pain is a common but poorly understood entity. Features of degeneration depend on which component of the motion segment is predominantly affected, and include disk space narrowing, vacuum phenomenon, disk desiccation, vertebral osteophyte formation, disk herniation, and facet arthrosis, but these features do not necessarily have any relationship to symptoms. Since most episodes of back pain resolve on their own, and most disk herniations spontaneously regress, imaging of low back pain, although widely performed, is probably not necessary in most cases.     

The problem of back pain in physiotherapists

The epidemiology, subjective perception of the cause, consequences and attitudes towards their back pain were compared in a representative group of 249 physiotherapists and a control group of 236 predominantly female workers from a wide range of non-medical occupations. In addition, the physiotherapists were asked about their involvement in back care education for others, their own training and their present speciality. A self-completion questionnaire was used and the results were analysed using the Statistical Package for Social Sciences (SPSS-X).

There were no significant differences between the groups in the occurrence of lifetime prevalence (ever had back pain?), annual prevalence (back pain last year), annual incidence (new cases of back pain last year), and point prevalence (back pain now). The anatomical distribution was similar, as was the number of episodes. Earlier precautions to avoid further back pain did not affect the recurrence rate.

Significantly more of the physiotherapists than the control groups identified the presence of occupational risk factors (P < 0.001)—physiotherapists attributed their back pain to work more frequently (P < 0.001) and the initial episode to an incident at work (P<0.01). For physiotherapists, lifting (P<0.05) and twisting (P<0.001) were more frequent mechanisms associated with the onset of back pain than for the control group.

Younger physiotherapists were seen to be particularly vulnerable, having a higher than expected annual prevalence of back pain. This group was more satisfied with their own training in lifting skills, though only 52% reported continued training after qualification and only 63% had had training in the clinical field. The physiotherapists showed an ability to cope with their back pain. No speciality was consistently implicated.

The possible explanations are discussed and the effectiveness of back care education is questioned. An ergonomic analysis of the working environment is recommended, in addition to a more realistic training programme for physiotherapists.     

Linking the Bournemouth Questionnaire for low back pain to the International Classification of Functioning,Disability and Health

Purpose: Understanding the content of health-related quality of life (HRQOL) questionnaires can facilitate comparison and selection of the most appropriate tool in the assessment of patients with low back pain. The International Classification of Functioning, Disability and Health (ICF), as part of the WHO-FIC, can be used as a standardised method for mapping and comparing HRQOL questionnaire content. The purpose of this study was to link the Bournemouth Questionnaire (BQ) to the ICF in order to assess and compare the content of the BQ to the brief ICF core sets for low back pain. Methods: The BQ was linked to the ICF following the rules described by Cieza and Stuki. Following the linking process, the results were further linked to the brief ICF core sets for low back pain. Results: The BQ covered 21 ICF categories within the domains of body functions and activities and participation. Only five meaningful concepts could not be linked to the ICF. The brief core sets for low back pain contain 35 categories, identified as important concepts in back pain patients. The BQ covered 10 of the categories of the brief core sets. Conclusion: HRQOL tools provide valuable information about the health status of patients. Content comparison based on ICF provides relevant information about the concepts covered and enables selection of the appropriate clinical tools. The BQ is easy to administer and is linked to a number of important concepts contained within the ICF and to concepts considered to be important in the assessment of patients with LBP.

• Implications for Rehabilitation

• Selecting appropriate health-related quality of life (HRQOL) tools can prove difficult, with such a variety of them available, and each with varying content.

• ICF provides a standardised framework for the content assessment of HRQOL tools.

• Understanding the content of HRQOL tools can facilitate better tool selection and assist in the accurate assessment of patients with low back pain.

     

Information needs of people with low back pain for an online resource: a qualitative study of consumer views

Abstract

Purpose: To identify the information needs of people with low back pain (LBP) in Australia, and the preferred methods to present this information online, as a basis for development of a patient-centred website. Available online LBP resources are limited in quality and content and it is not clear if they are meeting the needs of sufferers. Method: Focus groups and semi-structured telephone interviews, involving 28 people with LBP. Results: Seven categories of information were identified: reasons for LBP, treatment and management options, self-help information, psychological and social dimensions, lay stories, quality assurance of information and roles of different healthcare professionals and locally available services. Identified preferences for online presentation included: multimodality, emphasis on visual media, readability and interactivity. Participants had been unable to obtain desired LBP information using existing resources. Conclusions: This study provides important guidance for development of a patient-centred website grounded in the expressed needs and preferences of people with LBP. Understanding the breadth of patients’ questions and concerns is essential for provision of patient-centred information and interventions. Incorporating these with the current evidence base would provide an accessible and relevant LBP patient education referral point, which is currently lacking.

• Implications for Rehabilitation

• Use of the internet to obtain health information is increasing, although there is little evidence that existing low back pain websites are meeting the expressed needs of health consumers.

• Our research suggests that people with low back pain have difficulty finding relevant and trustworthy information about the condition on the internet.

• Taking patient information needs and presentation preferences into account when designing online information material will provide people with low back pain an accessible and relevant educational resource that is currently lacking.

     

Healing of painful intervertebral discs: implications for physiotherapy Part 2 — pressure change therapy: a proposed clinical model to stimulate disc healing

Abstract

Background: In Part 1 of this paper, we presented a comprehensive review of the literature, regarding pathophysiology of discogenic pain. Based on the evidence presented, we are suggesting clinical, self-management strategies to promote disc healing and treat disc pain in general.

Objectives: To suggest a physical therapy protocol for self-management of disc injuries and stimulation of disc healing.

Major findings: Inflammatory process after injury to the outer annulus is the most likely source of discogenic pain. Annulus is the tensile load bearing ‘skin’ of the disc and its histology and pathology are similar to other collagen tissues like tendons and ligaments. Conventional physiotherapy wisdom for the management of tendon and ligament injuries is applicant to annular tears. Disc pain without injury is common due to development of stress concentrations in the disc especially during prolonged, end-range postures. Spinal motion segment depends on an optimal disc function. Strategies for management of associated pathologies like apophyseal joint pain and muscle spasm are also considered on this paper.

Conclusion: Physical therapies should aim to promote healing in the disc periphery, by stimulating cells, boosting metabolite transport, discouraging adhesion formation, and preventing re-injury. The self-treatment approach presented in this paper, can potentially provide pain relief to a large number of back pain sufferers. This approach can be applied through information sessions and classes to help deal with the widening back pain pandemic.     

Update on Spinal Mobilisations with Leg Movement

Abstract

A case study demonstrates the use of spinal mobilisations with leg movement to treat a patient who presented with low back pain and sciatica. A prone lying technique is demonstrated, however, the author is not suggesting that this new technique should replace the side lying method which was described in 1995. Both have a place in the treatment of patients with low back pain and sciatica.     

Show me the skin! Does seeing the back enhance tactile acuity at the back?

A growing body of literature associates musculoskeletal disorders with cortical reorganisation. One condition in which reorganisation is established and treatments that ‘train the brain’ are being widely used is chronic back pain. Recent evidence suggests that treatments that involve tactile training are more effective if they incorporate multisensory mechanisms, most obviously vision. With regard to back pain however, we must first determine if tactile function is enhanced by incorporating other modalities. A series of three cross-over experiments were conducted in healthy pain-free subjects to determine whether tactile acuity is enhanced when participants can see the skin of their back during testing. An initial randomised cross-over experiment suggested tactile acuity was significantly enhanced when participants could see their backs (t(25) = −4.226, p < 0.001, r = 0.65). However, a second replication experiment was not corroborative. Both the second (F(3,66) = 1.00, p = 0.398) and third (t(9) = 0.969, p = 0.358) experiments suggested that seeing the back did not significantly affect tactile acuity, confirming that our initial results were likely due to chance. The principle that visual feedback improves tactile acuity at the hand does not apply to the back. These results strongly suggest that attempts to enhance tactile training by incorporating vision will not offer the benefit to treatment of back pain that has been observed for treatment of hand pain.     

Is standing balance altered in individuals with chronic low back pain? A systematic review

Purpose: To examine the static standing balance of individuals with chronic low back pain when compared to a healthy control group.

Methods: A search of available literature was done using PubMed, SPORTDiscus, CINAHL, and Scopus databases. Studies were included if they contained the following: (1) individuals with chronic low back pain 3?months or longer; (2) healthy control group; (3) quantified pain measurement; and (4) center of pressure measurement using a force plate. Two authors independently reviewed articles for inclusion, and assessed for quality using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross Sectional Studies. Cohen’s d effect size was calculated to demonstrate the magnitude of differences between groups.

Results: Nine articles were included in this review. Quality scores ranged from 5/8 to 8/8. Although center of pressure measures were nonhomogeneous, subjects with chronic low back pain had poorer performance overall compared to healthy controls. Despite inconsistencies in statistical significance, effect sizes were frequently large, indicating a lack of sufficient power in the included studies. Data were insufficiently reported among certain studies, limiting the ability of direct study comparison.

Conclusions: Results suggest that balance is impaired in individuals with chronic low back pain when compared to healthy individuals.

• Implications for rehabilitation

• Static balance is affected in individuals with chronic low back pain.

• Balance assessments should be completed for individuals with chronic low back pain.

• Results from balance assessments should be used to indicate areas of improvement and help guide the course of treatment, as well as reassess as treatment progresses.

     

Socioeconomic status predicts functional disability in patients participating in a back pain trial

Purpose. To investigate whether socioeconomic status in patients with back pain participating in a randomised controlled trial was predictive of functional disability (Roland Disability Questionnaire, RDQ).

Method. Secondary analysis of data (n = 949) from a national primary care trial of physical treatments for back pain (UKBEAM trial) using multilevel modelling. The three indicators were Townsend scores, educational levels and work status.

Results. All indicators were significant predictors of outcome after adjusting for baseline variables. As Townsend scores increased (indicating greater deprivation) RDQ scores (functional disability related to back pain) increased. Lower levels of educational attainment were associated with higher RDQ scores. Those ‘Not in Work’ reported markedly higher levels of RDQ scores which increased over time. There was no evidence that one particular treatment was more suitable for participants of different socioeconomic status.

Conclusions. The findings from this study add to the body of literature which suggests the importance of socioeconomic factors as an influence on health, including resultant disability related to chronic musculoskeletal conditions such as back pain. Work status was particularly dominant in our findings and may suggest that helping patients with back pain back to work where appropriate, is an especially important part of the management process.     

Risk Indicators in Low Back Pain

Injuries leading to low back pain can occur by direct trauma, overexertion or repetitive trauma. Overexertion is claimed by 60% of low back pain patients as the cause of injury. Of these patients with overexertion injuries, 66% implicated lifting and 20% pushing or pulling. It is, however, difficult to relate the workplace to the complaint of low back pain in a specific worker, and low back pain is found quite often in those with sedentary occupations.

The incidence, severity and potential disability are all related to the demands on the individual in the workplace. Among the factors implicated are the requirements for lifting (particularly when compared to the worker's lifting capacity), pushing and pulling, posture, and cyclic loading. Drivers of heavy vehicles have two to four times the average incidence of serious low back pain. This is probably due to the cyclic loading environment.

The general psychosocial environment (including that at work) is an important risk factor. The first attack of low back pain occurs in the teens or twenties. Low back pain is as frequent in females as males, although women in manual materials handling jobs are at greater risk. Posture, anthropometry and mobility measures have limited prognostic value. Muscle strength and physical fitness probably have some value. Radiographic findings have little pragmatic value.     

Occupational role performance in persons with back pain

Purpose: Back pain is a major cause of work disability but there is little data on the impact of back pain among persons who are working. The purpose of this study was to develop a measure of occupational role performance for individuals with back pain and to examine its relationship with sociodemo-graphic and work-related factors.

Method: Item analysis and reduction resulted in a short, eight-item Occupational Role Questionnaire (ORQ) consisting of two scales, a productivity scale and a satisfaction with work scale. The scales had good internal consistency and correlated as expected with the Roland and Morris Disability Scale.

Results: In a multivariate logistic model, significant negative effects on work satisfaction were observed for age 30–39 years relative to age 50 +, having a job that required lifting, and the level of disability.

Conclusion: The ORQ may have applications in studying the consequences of back pain and other chronic conditions in the workplace.     

Meeting the ranging of informational needs of chronic low back pain sufferers: Conceptual design and rationale of the interactive website ONESELF

Abstract

Purpose. Information plays an important role in the management and treatment of chronic pain conditions. Often, however, delivered information does not address specific difficulties of consumers. The present study illustrates the design and implementation of the website ONESELF - run by the Institute of Communication and Health of the University of Lugano - which has been created to meet die ranging of informational needs of chronic low back pain sufferers.

Method. ONESELF rests on an integrated idea of health literacy that highlights the kind of information consumers need to inform their decisions about back pain. This idea has been tested through a qualitative analysis of requests posted by users in the forum of ONESELF between July 2006 and December 2007.

Results. Users seek information to build their declarative (factual) and procedural knowledge, as well as to evaluate that knowledge and apply it to the context of their own life.

Conclusion. Online interactional tools such as ONESELF are a promising source of health communication, provided that the content manager of the website and the health professionals collaborate in a rigorously structured manner. ONESELF can benefit traditional medical consultations in helping screen requests from patients that do not need to see a doctor, and in acting as a repository of background information that saves consultation time for more urgent matters.     

A review of culturally adapted versions of the Oswestry Disability Index: the adaptation process,construct validity,test–retest reliability and internal consistency

Abstract

The Oswestry Disability Index (ODI) is a self-report-based outcome measure used to quantify the extent of disability related to low back pain (LBP), a substantial contributor to workplace absenteeism. The ODI tool has been adapted for use by patients in several non-English speaking nations. It is unclear, however, if these adapted versions of the ODI are as credible as the original ODI developed for English-speaking nations. The objective of this study was to conduct a review of the literature to identify culturally adapted versions of the ODI and to report on the adaptation process, construct validity, test–retest reliability and internal consistency of these ODIs. Following a pragmatic review process, data were extracted from each study with regard to these four outcomes. While most studies applied adaptation processes in accordance with best-practice guidelines, there were some deviations. However, all studies reported high-quality psychometric properties: group mean construct validity was 0.734?±?0.094 (indicated via a correlation coefficient), test–retest reliability was 0.937?±?0.032 (indicated via an intraclass correlation coefficient) and internal consistency was 0.876?±?0.047 (indicated via Cronbach’s alpha). Researchers can be confident when using any of these culturally adapted ODIs, or when comparing and contrasting results between cultures where these versions were employed.

• Implications for Rehabilitation

• Low back pain is the second leading cause of disability in the world, behind only cancer.

• The Oswestry Disability Index (ODI) has been developed as a self-report outcome measure of low back pain for administration to patients.

• An understanding of the various cross-cultural adaptations of the ODI is important for more concerted multi-national research efforts.

• This review examines 16 cross-cultural adaptations of the ODI and should inform the work of health care and rehabilitation professionals.

     

Getting the pain right: how low back pain patients manage and express their pain experiences

Purpose: Biopsychosocial interventions in low back pain (LBP) rehabilitation aim at preparing patients to accept and manage their pain conditions and to encourage them to maintain their everyday life routines. Although such approaches have demonstrated a positive effect, for example, in relation to return to work (RTW), few studies have explored how social contexts influence how pain is being managed. Using a theoretical approach that addresses pain as social performance, we illustrate how pain is expressed and managed in three different contexts: at the clinic, at home and at work. Methods: Qualitative in-depth interviews were conducted with eight patients who had followed a hospital-based RTW intervention. Results: Low back patients experience dilemmas of how to express their pain sensations and constantly evaluate whether the activities they participate in will ease or worsen their pain sensations. In this process, their behavior is guided by how they think their social role will be affected by their decision to abstain from or undertake the activities in question. Conclusions: Interventions in rehabilitation may benefit from knowledge of the social processes at play when LBP patients articulate, express and suppress their symptoms in their interaction with health professionals, workmates, families and friends.

Implications for Rehabilitation

Low back pain

• In order to manage pain, patients with low back pain are encouraged to exercise and to maintain their everyday activities.

• Choosing to become physically active, although in pain, is related to those social roles one wishes to maintain or support.

• Future interventions could offer support so that patients will be able both to maintain their social roles and to retire from social activities without their social roles being threatened.