Patients’ perceptions of self-management of chronic low back pain: evidence for enhancing patient education and support

Objectives

To explore the extent to which physiotherapy facilitated chronic low back pain (CLBP) patients to self-manage following discharge, and to explore patients’ perceptions of their need for self-management interventions or support and their preferences in terms of delivery.

Design

Qualitative study using semi-structured interviews to explore patients’ perceptions of various aspects of physiotherapy management of CLBP.

Setting

Physiotherapy departments in one geographical area of the UK National Health Service.

Participants

Twenty-five people who had received physiotherapy for CLBP within the previous 6 months.

Results

Adoption of self-management strategies was not achieved consistently in this group of participants. There was a strongly perceived need for self-management support following discharge from physiotherapy. Exercises were reportedly the most common self-management strategy in use. However, it was common for participants to perceive that physiotherapy had little influence on their CLBP management following discharge.

Conclusions

These results suggest that CLBP patients could be better facilitated to manage their condition. Providing self-management education in addition to the patient information and education provided traditionally, and providing self-management support in the form of direct access and/or review appointments or telephone calls is worthy of further investigation in this patient group.     

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.     

Analyzing chronic low back pain: the relative contribution of pain coping strategies

Sixty-two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity Index of the SCL-90R), and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%), but significant amount of variance in pain report. Patients scoring high on this factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.     

Electromyography-biofeedback for chronic low back pain: A qualitative cohort study

Background and AimsSurface electromyography-biofeedback (sEMG-BF) may reduce the burden of CLBP by improving physical functioning, sleep, pain catastrophizing, anxiety, and depression. This qualitative study investigated the impact of weekly EMG-BF sessions on adults with CLBP.MethodsTwenty-six individuals with CLBP participated in telephone interviews after completing an 8-week virtual sEMG-BF intervention. Trained interviewers conducted the 10-to-15-minute semi-structured interviews to understand participants’ experience with the intervention. Common themes and subthemes were identified and analyzed using MAXQDA 2022 software.ResultsParticipants were predominantly middle-aged females (M = 45, range of 19 – 66) who have had exposure to utilizing conventional therapies such as physical therapy, chiropractor, and massage for the treatment of CLBP. This study focused on participants who reported their experience of the main outcome study which included perceived reductions in CLBP symptoms, including pain and stress, and positive effects on self-awareness and sleep. Three overarching themes emerged and were further divided into subthemes: participants’ involvement (virtual experience, accessibility of device, and future recommendations) perceived benefits (participants gained awareness, recommendations for future treatment, met expectations, and implementation), and desire for flexibility (obstacles and COVID-19 Impact). No adverse effects were reported by any of the participants within the study.ConclusionsBoth physical and psychological improvements were reported by participants following an sEMG-BF intervention. Specific implementation procedures and critical barriers were identified. In particular, the ability to receive care for CLBP during the COVID-19 pandemic was important to participants.     

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

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

Relationships between forward head posture and lumbopelvic sagittal alignment in older adults with chronic low back pain

BackgroundAbnormal posture creates abnormal stress and strain in many spinal structures which are considered predisposing factors for chronic mechanical low back pain.PurposeTo examine the relationships among pain intensity, forward head posture (decreased craniovertebral angle) and lumbopelvic sagittal alignment (pelvic incidence, pelvic tilt, sacral slope, and lumbar lordosis) in chronic mechanical low back pain patients.MethodsA cross-section correlational study was conducted on one hundred patients. A numerical-pain-rating scale was used to determine pain intensity. Standardized standing lateral radiographs were analyzed to measure the spinopelvic angles. Reported data were analyzed using correlation coefficients, and regression analyses.ResultsLumbar lordosis had very strong positive correlations with each pain intensity and sacral slope. Pain intensity had a strong positive correlation with sacral slope. Moderate positive correlations highlighted between pelvic tilt and craniovertebral angle. Moreover, the pelvic incidence had weak positive correlations with each sacral slope and pelvic tilt. Negative correlations were strong between pelvic tilt and each of pain intensity, lumbar lordosis and sacral slope. Craniovertebral angle had moderate negative correlations with each of pain, lumbar lordosis, and sacral slope. However, the pelvic incidence had no relations with pain, craniovertebral angle lumbar lordosis. Overall, an association of demographic data and measured variables had a significant effect on the pain multi-regression equation prediction model. They accounted for 76.60% of the variation in pain.ConclusionAbnormal spinopelvic posture relates to chronic mechanical low back pain. There are significant associations among pain intensity, FHP and lumbopelvic sagittal alignment in chronic mechanical low back pain patients.     

A randomised controlled study of reflexology for the management of chronic low back pain

The use of complementary and alternative medicine (CAM) for the management of chronic low back pain (CLBP) continues to rise. However, questions regarding the efficacy of many CAM therapies for CLBP remain unresolved. The present study investigated the effectiveness of reflexology for CLBP. A pragmatic randomised controlled trial was conducted. N=243 patients were randomised to one of three groups: reflexology, relaxation, or non-intervention (usual care). All completed a questionnaire booklet before and after the treatment phase, and at six months follow up. This measured their general health status, pain, functioning, coping strategies and mood. After adjusting for pre-treatment scores repeated measures ANCOVA found no significant differences between the groups pre and post treatment on the primary outcome measures of pain and functioning. There was a main effect of pain reduction, irrespective of group. Trends in the data illustrated the pain reduction was greatest in the reflexology group. Thus, the current study does not indicate that adding reflexology to usual GP care for the management of CLBP is any more effective than usual GP care alone.     

The course of chronic and recurrent low back pain in the general population

Using latent class analysis (LCA), a previous study on patients attending primary care identified four courses of low back pain (LBP) over the subsequent 6 months. To date, no studies have used longitudinal pain recordings to examine the “natural” course of recurrent and chronic LBP in a population-based sample of individuals. This study examines the course of LBP in the general population and elaborates on the stability and criterion-related validity of the clusters derived. A random sample of 400 individuals reporting LBP in a population-based study was asked to complete a comprehensive questionnaire at the start and end of the year’s survey, and 52 weekly pain diaries in between. The latter were analyzed using LCA. 305 individuals returned more than 50% of the diaries. Four clusters were identified (severe persistent, moderate persistent, mild persistent, and fluctuating). The clusters differed significantly with regards to pain and disability. Assessment of cluster stability showed that a considerable proportion of patients in the “fluctuating” group changed their classification over time. Three of the four clusters describing the typical course of pain matched the clusters described previously for patients in primary care. Due to the population-based design, this study achieves, for the first time, a close insight into the “natural” course of chronic and recurrent low back pain, including individuals that did not necessarily visit the general practitioner. The findings will help to understand better the nature of this pain in the general population.     

Training peers to support older people with chronic low back pain following physiotherapy discharge: a feasibility study

Objective

To determine the feasibility and acceptability of a training programme for peer volunteers to support older adults with chronic low back pain (CLBP) following discharge from physiotherapy.

Disuse and deconditioning in chronic low back pain: concepts and hypotheses on contributing mechanisms.

For years enhancement of a patient's level of physical fitness has been an important goal in rehabilitation treatment in chronic low back pain (CLBP), based on the hypothesis that physical deconditioning contributes to the chronicity of low back pain. However, whether this hypothesis in CLBP holds is not clear. In this paper, possible mechanisms that contribute to the development of physical deconditioning in CLBP, such as avoidance behaviour and suppressive behaviour, are discussed. The presence of both deconditioning-related physiological changes, such as muscle atrophy, changes in metabolism, osteoporosis and obesity as well as deconditioning related functional changes, such as a decrease in cardiovascular capacity, a decrease in muscle strength and impaired motor control in patients with CLBP are discussed. Results of studies on the level of physical activities in daily life (PAL) and the level of physical fitness in patients with CLBP compared to healthy controls were reviewed. In studies on PAL results that were either lower or comparable to healthy subjects were found. The presence of disuse (i.e., a decrease in the level of physical activities in daily life) in patients with CLBP was not confirmed. The inconclusive findings in the papers reviewed may partly be explained by different measurement methods used in research on PAL in chronic pain. The level of physical fitness of CLBP patients also appeared to be lower or comparable to the fitness level of healthy persons. A discriminating factor between fit and unfit patients with back pain may be the fact that fit persons more frequently are still employed, and as such may be involved more in physical activity. Lastly some suggestions are made for further research in the field of disuse and deconditioning in CLBP.     

Cognitive distortion and disability in chronic low back pain

Numerous authors have suggested that cognitions play an important role in the development, maintenance, and treatment of chronic low back pain (CLBP). However, little evidence exists to support the association between cognitive variables and the CLBP problem. The present study examined the relationship of cognitive distortion, as measured by the Cognitive Error Questionnaire, to disability, as measured by the Sickness Impact Profile, in a sample of 138 CLBP patients. As predicted, cognitive distortion was consistently related to several aspects of disability. The cognitive variables accounted for variance in disability beyond that accounted for by severity of pain, number of pain treatments, and depression. Also as predicted, cognitive distortion concerning low back pain situations was more closely correlated with disability than was distortion concerning general, nonpain situations. Overgeneralization was the specific cognitive error most closely and consistently correlated with disability. The results are interpreted as consistent with a cognitive-behavioral model of CLBP.The authors would like to thank Holly Waldron, Dennis Turk, and several anonymous reviewers for their comments on an earlier version of this paper.     

本体感觉神经肌肉促进技术治疗慢性非特异性腰痛的疗效观察

目的：观察本体感觉神经肌肉促进技术（PNF）对慢性非特异性腰痛（CNLBP）的影响。方法：选取CNLBP患者41例,随机分为观察组21例和对照组20例,2组患者均采用常规康复治疗,观察组在此基础上增加PNF训练。于治疗前后采用视觉模拟评分法（VAS）、Oswestry功能障碍指数问卷表（ODI）和健康状况调查简表（SF-36）对患者的疗效及功能进行评估,表面肌电图仪采集竖脊肌、腹直肌和腹外斜肌的肌电信号,分析均方根值（RMS）和平均肌电值（AEMG）,并计算屈曲-放松比值（FRR）。结果：治疗4周后,2组患者的VAS评分及ODI指数均较治疗前明显下降（均P＜0.05）,且观察组均低于对照组（均P＜0.05）;SF-36评分和竖脊肌、腹直肌、腹外斜肌的RMS值及竖脊肌FRR值均较治疗前明显提高（均P＜0.05）,且观察组均高于对照组（均P＜0.05）。结论：在常规康复治疗的基础上增加PNF训练可显著改善CNLBP患者的功能,并提高疗效。     

"Being" in pain: the role of self-discrepancies in the emotional experience and activity patterns of patients with chronic low back pain

Chronic pain not only interferes with daily activities, it may also have a negative impact on the perceived integrity of one’s self through self-discrepancies. Self-discrepancies are experienced distances between the actual self and self-guides that can exist from 2 perspectives (ie, own and other). Self-discrepancies are associated with negative mood states and incite self-regulatory behavior in order to reduce these discrepancies. The present study was aimed at replicating the emotional consequences of self-discrepancies in patients with chronic low back pain, and extending current knowledge of the behavioral consequences of self-discrepancies (ie, behavioral activity patterns such as avoidance and persistence). A cross-sectional design was employed with 83 patients who completed a number of self-report measures. We hypothesized that ideal and ought discrepancies, as well as feared congruencies were associated with depressed and anxious mood. On the behavioral level, a U-shaped relationship was hypothesized between ideal and ought self-discrepancies and persistence behavior, whereas feared self-discrepancies were hypothesized to be related to avoidance behavior. Results were partially in line with the hypotheses. With respect to the emotional consequences, feared (own and other) self-discrepancies were predictive of depressive and anxious mood. With regard to activity patterns, results showed a U-shaped relationship between ideal-other self-discrepancies and persistence behavior and a positive relationship between feared-own self-discrepancies and avoidance behavior. In contrast to expectations, none of the other self-discrepancies was related to activity patterns. Of interest was that avoidance, but not persistence behavior, was predictive of higher levels of disability and lower levels of quality of life.     

The effect of the Alexander Technique on pain intensity in patients with chronic low back pain: A randomized controlled trial

ObjectiveThe present study was performed to determine the effect of the Alexander Technique on the intensity of pain in patients with chronic low back pain (LBP).MethodsThis study is a clinical trial that was performed on 80 patients with chronic LBP in Kashan, Iran. Participants were randomly assigned in control and intervention groups. To assess the participants’ LBP, a visual analog scale of pain (VAS-Pain) was completed by both groups. In the intervention group, in addition to routine care for LBP patients, the Alexander Technique was performed in three 60-min sessions per week for 12 weeks. The control group participants received routine care for LBP patients. The two groups completed the VAS-Pain scale immediately after and one month after the intervention.ResultsThe results showed that there was no statistically significant difference between the two groups in terms of demographic characteristics and mean pain intensity score before the intervention (p > 0.05). Immediately after and then one month after the intervention, there was statistically significant differences between the two groups regarding the mean scores of pain (p < 0.05). The results of repeated measures ANOVA showed that, in the intervention group, the mean score of pain had decreased over time (p < 0.05).ConclusionThe results of the present study showed that the Alexander Technique was effective in reducing the intensity of pain among the participants. We recommend the Alexander Technique as a useful and effective intervention for reducing chronic LBP.     

Sensory characteristics of chronic non-specific low back pain: A subgroup investigation

It has been proposed that patients with chronic non-specific low back pain (CNSLBP) can be broadly classified based on clinical features that represent either predominantly a mechanical pain (MP) or non-mechanical pain (NMP) profile. The aim of this study was to establish if patients with CNSLBP who report features of NMP demonstrate differences in pain thresholds compared to those who report MP characteristics and pain-free controls. This study was a cross-sectional design investigating whether pressure pain threshold (PPT) and/or cold pain threshold (CPT) at three anatomical locations differed between patients with mechanical CNSLBP (n = 17) versus non-mechanical CNSLBP (n = 19 and healthy controls (n = 19) whilst controlling for confounders. The results of this study provide evidence of increased CPT at the wrist in the NMP profile group compared to both the MP profile and control subjects, when controlling for gender, sleep and depression (NMP versus MP group Odds Ratio (OR): 18.4, 95% confidence interval (CI): 2.5–133.1, p = 0.004). There was no evidence of lowered PPT at any site after adjustment for confounding factors. Those with an MP profile had similar pain thresholds to pain-free controls, whereas the NMP profile group demonstrated elevated CPT's consistent with central amplification of pain. These findings may represent different pain mechanisms associated with these patient profiles and may have implications for targeted management.     

Balance in chronic low back pain patients compared to healthy people under various conditions in upright standing

Objective. To determine whether balance responses of chronic low back pain patients differed from healthy controls under various upright standing conditions which challenged the balance system.

Methods. Eight chronic low back pain patients and eight controls performed seven postural tasks which involved manipulation of visual, vestibular, and proprioceptive input as well as body orientation. The unbiased root mean square, the mean power frequency and the mean position of the centre of pressure were calculated from force plate readings. A pain scale and two questionnaires were used to evaluate the severity of disability and the scores were correlated with the force plate measures. The reliability of the force plate measures was determined.

Results. A significant increase in the root mean square in the medial–lateral direction for the chronic low back pain patients as a group was found during tasks which involved removal of vision, especially when combined with increased task complexity. The root mean square and mean power frequency in the medial–lateral plane were reliable for the majority of the tasks.

Conclusion. The root mean square in the medial–lateral direction was reliable and sensitive enough to measure an increase in postural sway of chronic low back pain patients as a group compared to healthy controls when the task involved increased complexity and removal of visual information.

Relevance

A reliable measure of whole body performance obtained during simple postural tasks, such as the root mean square in the medial–lateral plane, may be used to distinguish chronic low back pain patients as a group from a healthy population. Further uses may include the development and guidance of chronic low back pain treatment and evaluation of recovery progress.     

Efficacy and tolerability of buccal buprenorphine in opioid-naive patients with moderate to severe chronic low back pain

Objectives: Buprenorphine HCl buccal film has been developed for treating chronic pain utilizing BioErodible MucoAdhesive (BEMA^®) delivery technology. Buccal buprenorphine (BBUP; Belbuca^TM, Endo Pharmaceuticals) was evaluated for the management of moderate to severe chronic low back pain (CLBP) requiring around-the-clock analgesia in a multicenter, double-blind, placebo-controlled, enriched-enrollment, randomized-withdrawal study in opioid-naive patients.

Methods: Patients (n = 749) were titrated to a dose of BBUP (range, 150–450 µg every 12 h) that was generally well tolerated and provided adequate analgesia for ≥14 days, and then randomized to BBUP (n = 229) or placebo (n = 232), respectively. The primary efficacy variable was the change from baseline to week 12 of double-blind treatment in the mean of daily average pain intensity scores (numeric rating scale from 0 [no pain] to 10 [worst pain imaginable]).

Results: Patients were experiencing moderate to severe pain at study entry: mean (SD) = 7.15 (1.05). Following titration, pain was reduced to the mild range; 2.81 (1.07). After randomization, mean (SD) pain scores increased from baseline to week 12 more with placebo (1.59 [2.04]) versus BBUP: (0.94 [1.85]) with a significant between-group difference (?0.67 [95% CI: ?1.07 to ?0.26]; p = 0.0012). A significantly larger percentage of patients receiving BBUP versus placebo had ≥30% pain reduction (63% vs 47%; p = 0.0012). During double-blind treatment, the most frequent adverse events (AEs) with BBUP were nausea (10%), constipation (4%) and vomiting (4%). The most common AEs with placebo were nausea (7%), upper respiratory tract infection (4%), headache (3%) and diarrhea (3%).

Conclusions: These findings demonstrate the efficacy and tolerability of BBUP among opioid-naive patients requiring around-the-clock opioid treatment for CLBP.     

Differences in activity‐related behaviour among patients with chronic low back pain

The aim of the present study was to compare the subjectively reported and objectively assessed activity‐related characteristics of patients with Chronic Low Back Pain (CLBP) who were classified according to their scores on the Patterns of Activity Measure‐Pain (POAM‐P) into avoiders, persisters, mixed performers (i.e. high scores on both avoidance and persistence behaviour) or functional performers (i.e. low scores on avoidance and persistence behaviour). Patients carried an electronic diary during 14 days to assess the self‐reported activity and pain intensity levels in daily life. An accelerometer was used to objectively assess their activity level during the same time period. Results were available for 79 patients. Avoiders, persisters and mixed performers showed a higher level of self‐reported disability than functional performers. Avoiders were characterized by a low level of self‐reported habitual activities and persisters by long objectively measured daily uptime. The objectively assessed level of physical activity did not differ between the four groups. A further analysis tested the association between pain intensity levels and self‐reported and objectively assessed daily life activity levels in avoiders and persisters. In persisters, a higher level of self‐reported activities in daily life was related to increased pain. The objectively assessed activity level was not associated with pain intensity.     

The experience of chronic back pain: accounts of loss in those seeking help from pain clinics.

BACKGROUND: This study responded to the need for greater understanding of the experiences that help to shape the worldviews of chronic back patients as they seek help from pain clinics. AIM: To elaborate on the lived experience of chronic back pain in those actively seeking help from pain clinics. METHODS: This was a qualitative study, based on an interpretative phenomenological approach. As part of in-depth interviews, participants were invited to 'tell their story' from the time their pain began. Participants were twelve male and eight female patients, all of whom were diagnosed as having chronic benign back pain and had recently attended one of two pain clinics as new referrals. The data were analysed thematically. FINDINGS: Loss was one of five major themes to emerge. The narrative accounts revealed a catalogue of socio-economic and other material losses including loss of physical and mental abilities, occupational and social activities, job or role. In those of working age, these led to financial hardship and changes in interpersonal relationships, culminating in loss of self-worth, future and hope. CONCLUSIONS: The findings suggest that material losses, as well as perceptions of loss, are prominent issues for those of working age seeking help from pain clinics for chronic back pain, and may need to be acknowledged and addressed as part of therapeutic interventions. The possibility of age-related differences in pain-related loss may be worthy of further investigation.