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

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

Design and control of an active 1-DoF mechanism for knee rehabilitation

A 1-DoF robot is designed and fabricated to be used for knee rehabilitation training. The mechanism (robot) is designed to perform specific set of exercises while the patient is sitting on a chair. The therapy process for patients has different stages; each stage consists of specific exercises to recover the knee to its condition before injury. The maximum torque of healthy joint during the extension/flexion exercise is evaluated by simulation and suitable actuator is selected based on the results. A prototype is then fabricated as a platform to evaluate the design and control concepts. The experiment procedure consisting of three stages of therapy indicates good tracking performance and safe operation of the system.

• Implication for Rehabilitation

• A 1-DoF mechanism for knee rehabilitation has been designed to perform three stages of therapy: passive, active assist and active resist.

• The assistive and resistive torque, during active assist and active resist stages, can be set according to the progress in therapy.

• The results of this study suggest the system has the potential to result in various benefits including reduction of physical workload of physiotherapists and improved repeatability.

     

The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy

The aim of this study was to determine the extent to which a number of distinct cognitive factors were differentially related to the levels of pain and disability reported by 183 chronic low back pain (CLBP) patients presenting for physiotherapy. After adjusting for demographics, the cognitive factors accounted for an additional 30% of the variance in pain intensity, with functional self-efficacy (beta=-0.40; P<0.001) and catastrophizing (beta=0.21; P<0.01) both uniquely contributing to the prediction of outcome. The cognitive factors also explained an additional 32% of the variance in disability after adjusting for demographics and pain intensity (total R(2)=0.61). Higher levels of functional self-efficacy (beta=-0.43; P<0.001) and lower levels of depression (beta=0.23; P<0.01) were uniquely related to lower levels of disability. Our findings clearly show that there is a strong association between cognitive factors and the levels of pain and disability reported by CLBP patients presenting for physiotherapy. Functional self-efficacy emerged as a particularly strong predictor of both pain intensity and disability. In view of our findings it would seem that targeting specific cognitive factors should be an integral facet of physiotherapy-based treatments for CLBP.     

The effect of a group education programme on pain and function through knowledge acquisition and home-based exercise among patients with knee osteoarthritis: A parallel randomised single-blind clinical trial

Objectives

To assess the effect of a group education programme on pain and function through knowledge acquisition and a home-based exercise programme.

Design

A parallel randomised single-blind clinical trial.

Participants

Fifty patients aged 65 years or over with knee osteoarthritis.

Interventions

The study group (n = 25) was given a group education programme once a week for 4 weeks, followed by a self-executed home-based exercise programme. The controls (n = 25) were given a brief course in short-wave diathermy treatment.

Main outcome measures

Patients were assessed before the intervention, after the intervention (4 weeks) and again 8 weeks later (follow-up) using the Western Ontario McMaster Osteoarthritis Index (WOMAC), the repeated sit-to-stand test and the get-up-and-go test.

Results

At 4 weeks, there was a significant improvement in both groups in all outcome variables except the WOMAC stiffness score; for example, the WOMAC total score was reduced by a mean of 9.5 points [95% confidence interval (CI) −12.3 to −6.7]. However, at follow-up, patients in the study group demonstrated continued improvement in the get-up-and-go test and the WOMAC total, pain and disability scores, but no such improvement was noted among the controls. This difference was significant; for example, the difference in mean WOMAC total score between the groups was −9.0 points (95%CI −14.5 to −3.4).

Conclusion

A simple group education programme for patients with knee osteoarthritis is associated with improved functional abilities and pain reduction. Further study is required to determine if this positive effect can be maintained over a longer period.     

Adding Temporomandibular joint treatments to routine physiotherapy for patients with non-specific chronic neck pain: A randomized clinical study

IntroductionNeck Pain can be related to the disorders of other adjacent areas such as the Temporomandibular Joint (TMJ). This study aimed to investigate whether there is value in adding TMJ treatments to routine physiotherapy in patients with non-specific chronic neck pain compared with a control group.MethodsA randomized, single-blind, clinical study desined including two groups of patients. Group A (20 people) received routine physiotherapy for neck pain and group B (20 people) received TMJ manual therapy plus exercise therapy in addition to routine physiotherapy for neck pain. The Treatment program included six sessions for two days a week over a period of 21 days. Assessments were performed during the first session, in the last session and one month after treatment as a follow-up. Outcome measures included neck range of motion (ROM), neck disability index (NDI) and visual analogue scale (VAS). Before starting the study, the reliability of methods for measuring neck ROM was evaluated.ResultsParticipants were 21 women and 19 men. Initially, a pilot study was carried out on the 40 volunteers to assess the reliability of the measurement methods, and the results were acceptable. With both the control group and the intervention group, the indexes showed significant improvement (p < 0.001), although the intervention group showed more improvement (p < 0.001).ConclusionThis result means adding treatments of TMJ to routine neck physiotherapy can magnify the effect of the intervention, a significant change still in evidence at follow up. Moreover, given the clinically important differences, our results for VAS and NDI were acceptable.     

A prospective study of patients with chronic back pain randomised to group exercise, physiotherapy or osteopathy

Objective

To investigate the difference in outcome between patients treated with group exercise, physiotherapy or osteopathy.

Design

Prospective study of patients referred at random to one of three treatments, with follow-up 6 weeks after discharge and after 12 months.

Setting

National Health Service physiotherapy department at St Albans City Hospital, part of the West Hertfordshire Musculoskeletal Therapy Service.

Participants

Two hundred and thirty-nine patients aged 18-65 years recruited from referrals to the physiotherapy department with chronic low back pain.

Interventions

Eligible patients were randomised to group exercises led by a physiotherapist, one-to-one predominantly manipulative physiotherapy, or osteopathy.

Main outcomes

Oswestry Disability Index (ODI), EuroQol-5D, shuttle walking test and patients’ subjective responses to pain and treatment.

Results

All three treatments indicated comparable reductions in mean (95% confidence intervals) ODI at 6-week follow-up: group exercise, −4.5 (−0.9 to −8.0); physiotherapy, −4.1 (−1.4 to −6.9); and osteopathy, −5.0 (−1.6 to −8.4). Attendance rates were significantly lower among the group exercise patients. One-to-one therapies provided evidence of greater patient satisfaction.

Conclusion

The study supports the use of a variety of approaches for the treatment of chronic low back pain. Particular attention needs to be given to the problems of attracting enough participants for group sessions, as these can be difficult to schedule in ways that are convenient for different participants.     

The role of pain for early rehabilitation in fast track total knee arthroplasty

Purpose.?To investigate the relationship between early functional mobility and pain intensity in a fast track program after total knee arthroplasty (TKA).

Methods.?One hundred consecutive patients operated with TKA in an orthopaedic unit at a University hospital were prospectively studied. Measurements of independence in transfer and ambulation (Cumulated Ambulation Score), pain intensity (Verbal Analog Scale (VAS)), range of knee motion, functional mobility (‘Timed Up & Go’ (TUG) test), and walking distance were recorded daily from the first postoperative day until discharge.

Results.?On the first postoperative day, 90% of the patients were able to walk independently with median pain intensity of ≤5 on VAS. Of these, 78% walked?>?70?m. All patients walked independently on postoperative Day 2 with pain intensity of ≤4. On the day of discharge, all patients walked with crutches with pain intensity of ≤3, walking distance?>?70?m, median range of motion 10–80°, and median test time of the ‘TUG’ 19.2?s. The length of hospital stay was median 3 days.

Conclusion.?Pain has a limited influence on the functional recovery beyond the first postoperative day after TKA, thereby allowing early physiotherapy.     

Predictors for global perceived effect after physiotherapy in patients with neck pain: an observational study

Objective

To investigate the prognostic importance of a number of sensorimotor and psychological factors for global perceived effect (GPE) after physiotherapy in patients with neck pain. In addition to baseline values, change scores were used as independent variables to identify treatment-modifiable factors.

腰痛患者康复住院费用的分析及预测

目的研究康复科腰痛患者住院费用的特点并了解目测类比疼痛评分法(VAS)对住院费用的预测。方法采用临床评定调查及查阅住院病历来收集资料的方法,用VAS评分。结果经统计学分析(t检验),康复科住院费用中床位费、放射费、药费和治疗费之间有显著差别(P<0.001);人均住院时间与人均住院总费用有很好的相关性(r=0.650,P<0.001),VAS与人均住院总费用有很好的相关性(r=0.335,P<0.01)。结论在康复住院费用中,治疗费用最高,其次为药费;住院时间越长,费用越高;女性患者住院费用高于男性。患者康复住院费用与疼痛程度有关;VAS能较好地预测腰痛患者的住院费用。     

The effect of a physiotherapy education compared with a non-healthcare education on the attitudes and beliefs of students towards functioning in individuals with back pain: An observational, cross-sectional study

Objectives

To investigate the difference in attitudes: (1) between first and fourth year physiotherapy students towards functioning in individuals with back pain; and (2) between physiotherapy students and non-healthcare students towards functioning in individuals with back pain.

Design

Observational, cross-sectional study.

Setting

Glasgow Caledonian University, Scotland, UK.

Participants

First year physiotherapy (n = 61) and non-healthcare students (n = 61), and fourth year physiotherapy (n = 62) and non-healthcare students (n = 62).

Main outcomes

All participants completed the Health Care Providers’ Pain and Impairment Relationship Scale (range 15 to 105). This questionnaire measures attitudes towards functioning in individuals with back pain.

Results

Fourth year physiotherapy students had more positive attitudes towards functioning in individuals with back pain than first year physiotherapy students [57.4 vs 66.6 (mean difference −9.2, 95% confidence interval −12.2 to −6.1, P < 0.01)]. Similarly, fourth year non-healthcare students had more positive attitudes towards functioning in individuals with back pain compared with first year non-healthcare students [69.2 vs 65.3 (mean difference −3.9, 95% confidence interval −7.2 to −0.5, P = 0.03)]. Physiotherapy students had more positive attitudes than non-healthcare students in the first year [66.6 vs 69.2 (mean difference −2.6, 95% confidence interval −5.5 to 0.4, P = 0.08)] and the fourth year [57.4 vs 65.3 (mean difference −7.9, 95% confidence interval −11.4 to −4.4, P < 0.01)] of study.

Conclusion

These findings suggest that physiotherapy education brings about positive student attitudes towards functioning in individuals with back pain. This may be partly attributable to receiving a university degree education, but would appear to be further enhanced by specifically receiving a physiotherapy degree. This may facilitate students to become more evidence-based practitioners following qualification.     

Potential impact of early physiotherapy in the emergency department for non-traumatic neck and back pain

BACKGROUND: Musculoskeletal complaints, especially non-traumatic neck and back pain, are routinely encountered in the emergency department (ED) and lead to ED overcrowding, a burgeoning wait time for physiotherapy and outpatient orthopedic reviews. The study aimed to evaluate the impact of early physiotherapy evaluation and treatment (EPET) vs. standard care (SC) on clinical outcomes for patients presenting to the ED with non-traumatic neck and back pain.     

A national framework for supporting improvements in the physiotherapy assessment and management of low back pain: the Scottish experience

Background

Similar to other countries worldwide, Scotland lacked a national view of whether the quality of the physiotherapy management of low back pain was compliant with national guidelines. Anecdotal evidence suggested that standards of care varied considerably despite the wide availability of clinical guidelines to clinicians.

Aim

To develop a framework that supports National Health Service (NHS) Scotland in providing consistently applied high-quality physiotherapy assessment and management of low back pain in line with guideline recommendations.

Design

Prospective, multicentred national study, data collection and improvement phase.

Setting

All NHS boards in Scotland (n = 14) plus two private provider sites.

Participants

One hundred and eighty-six individual NHS sites and two private providers of services to patients with low back pain.

Method

A national dataset was developed from evidence- and consensus-based guideline sources. All sites collected data (two 5-week periods) over 1 year (2008-2009) using a web-based database. This was interspersed by an improvement phase during which required improvements were considered and implemented. Issues were shared through a national network and national meeting.

Results

Data from 2147 patients showed improvements in the documented physiotherapy management of low back pain over the two cycles. All participants developed and implemented remedial action plans based on the results of the first cycle.

Conclusion

It is possible to implement a framework, which is led nationally but driven and owned locally, supporting physiotherapists in an active programme of locally determined improvement. However, although process and outcome are linked, the direct impact of this initiative on patient outcome is not known.     

A comparison of the knowledge of chronic pain and its management between final year physiotherapy and medical students

The scientific literature reveals a surprising lack of knowledge of chronic pain mechanisms and its management amongst health care professionals, including physicians and physiotherapists. There is little information directly related to a comparison between medical and physiotherapy students’ knowledge of chronic pain. This study aimed to determine and compare the level of knowledge of chronic pain and its management between final year medical (n=126) and physiotherapy students (n=62). A chronic pain questionnaire which included two sections on knowledge and one section on management was used to gather quantitative and qualitative data. Final year physiotherapy students were found to have statistically greater knowledge of chronic pain than final year medical students (p=0.01 and p=0.002). In contrast, medical students were found to have statistically significantly greater understanding of the management of patients with chronic pain (p=0.001). Male students from both groups scored significantly higher in the management section (p=0.008) as did older students (p=0.01). There was a lack of understanding, in varying degrees, of central sensitization, opioid addition, fear‐avoidance and a number of students from both cohorts appeared to bring a curative focus to the treatment of chronic pain. One way forward could be found in the interprofessional agenda. This will offer students from different disciplines opportunities to understand their different roles and enhance each others’ learning base so that a biopsychosocial framework of care can be implemented. In this way, physiotherapists could learn more about the drug management of chronic pain and medical students could explore more collaborative patient‐centred paradigms that address issues such as self‐efficacy, self‐management and patient empowerment. More focus needs to be paid to the education of the health professionals regarding their assumptions and understanding what ‘vulnerable’ means in a tissue in comparison to a person.     

Widespread sensitization in patients with chronic pain after revision total knee arthroplasty

Pain and sensitization are major issues in patients with osteoarthritis both before and after total knee arthroplasty (TKA) and revision TKA (re-TKA). The aim of this study was to assess sensitization in patients with and without chronic pain after re-TKAs. Twenty patients with chronic knee pain and 20 patients without pain after re-TKA participated. Spreading of pain was evaluated as the number of pain sites using a region-divided body chart. The pressure pain threshold (PPT) and pressure pain tolerance (PTT) were assessed by cuff algometry at the lower leg. Temporal summation of pain was assessed by recordings of the pain intensity on a visual analog scale (VAS) during repeated cuff pressure stimulations. Conditioning pain modulation (CPM) was recorded by experimental tonic arm pain by cuff pressure stimulation and assessment of PPTs on the knee, leg, and forearm using handheld pressure algometry. Participants with pain after re-TKA compared to participants without pain demonstrated: (1) significantly more pain sites (P = .004), (2) decreased cuff PPTs and PTTs at the lower leg (P < .001), (3) facilitated temporal summation (P < .001), and (4) impaired CPM (P < .001). Additionally, significant correlations between knee pain intensity and cuff PPTs, temporal summation, and CPM and between total duration of knee pain and temporal summation were found (P < .05). This study demonstrated widespread sensitization in patients with pain after re-TKA and highlighted the importance of ongoing nociceptive input for the chronification process. This has important implications for future revisions, and precautions should be taken if patients have widespread sensitization.     

The psychometric properties of an Arabic numeric pain rating scale for measuring osteoarthritis knee pain

Purpose: The aims of this study were to translate the numeric rating scale (NRS) into Arabic and to evaluate the test–retest reliability and convergent validity of an Arabic Numeric Pain Rating Scale (ANPRS) for measuring pain in osteoarthritis (OA) of the knee.

Methods: The English version of the NRS was translated into Arabic as per the translation process guidelines for patient-rated outcome scales. One hundred twenty-one consecutive patients with OA of the knee who had experienced pain for more than 6 months were asked to report their pain levels on the ANPRS, visual analogue scale (VAS), and verbal rating scale (VRS). A second assessment was performed 48 h after the first to assess test–retest reliability. The test–retest reliability was calculated using the intraclass correlation coefficient (ICC_2,1). The convergent validity was assessed using Spearman rank correlation coefficient. In addition, the minimum detectable change (MDC) and standard error of measurement (SEM) were also assessed.

Results: The repeatability of ANPRS was good to excellent (ICC 0.89). The SEM and MDC were 0.71 and 1.96, respectively. Significant correlations were found with the VAS and VRS scores (p?<0.01).

Conclusions: The Arabic numeric pain rating scale is a valid and reliable scale for measuring pain levels in OA of the knee.

• Implications for Rehabilitation

• The Arabic Numeric Pain Rating Scale (ANPRS) is a reliable and valid instrument for measuring pain in osteoarthritis (OA) of the knee, with psychometric properties in agreement with other widely used scales.

• The ANPRS is well correlated with the VAS and NRS scores in patients with OA of the knee.

• The ANPRS appears to measure pain intensity similar to the VAS, NRS, and VRS and may provide additional advantages to Arab populations, as Arabic numbers are easily understood by this population.

     

An integrated care pathway for the management of low back pain

Low back pain is a disabling condition that is responsible for a considerable amount of health service expenditure [HMSO, London, 1994, p. 1; The Back Pain Revolution. Churchill Livingstone, London, 1999]. Following national recommendations from the Clinical Standards Advisory Group [HMSO, London, 1994, p. 1] and the Royal College of General Practitioner Guidelines [Royal College of General Practice, London, 1996, 1999], local initiatives have attempted to integrate this advice into care pathways for low back pain. This paper will detail the background development, construction and audit of an integrated care pathway for the management of patients with acute low back pain in North Staffordshire.     

Potential interaction of experimental knee pain and laterally wedged insoles for knee off-loading during walking

Background

Laterally wedged insoles are one of the gait modifications potentially slowing down progression of medial knee osteoarthritis. Clinical studies have, however, found large individual differences in the biomechanical effect and an insufficient pain reduction. To clarify if and how pain mediates mechanical changes during gait the current study investigated how acute experimental knee pain changes the mechanical effect of laterally wedged insoles in healthy subjects during walking.

Methods

3D gait analysis was carried out for twelve healthy individuals. The study followed a cross-over design and data were collected with both a neutral and a 10-degree laterally wedged insole with experimental pain induced by hypertonic and isotonic saline injections into the infrapatellar fat pad. Peak knee adduction moment was the primary outcome. A repeated ANOVA (analysis of variance) was used to evaluate the relationship between the factors wedge, condition and test number.

Findings

Wedges significantly reduced peak knee adduction moment but experimental knee pain did only marginally affect its magnitude in either condition. While frontal plane mechanics were relatively unaffected by pain, the sagittal plane knee extension moment increased with laterally wedging (P = 0.008), whereas late knee flexion moment was reduced by experimental knee pain (P = 0.04).

Interpretation

The effect of laterally wedged insoles in attenuating knee adduction moment during walking is independent of experimental knee pain. The present study provides evidence that subjects with experimental knee pain reduce knee loading by reducing extension moment, whereas lateral wedges have the opposite effect and increase the extension moment.