Albère Köke

Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial

&NA; Since pain‐related fear may contribute to the development and maintenance of chronic low back pain (CLBP), an exposure in vivo treatment (EXP) was developed for CLBP patients. We examined the effectiveness as well as specific mediating mechanisms of EXP versus operant graded activity (GA) directly and 6 months post‐treatment in a multi‐centre randomized controlled trial. In total, 85 patients suffering from disabling non‐specific CLBP reporting at least moderate pain‐related fear were randomly allocated to EXP or GA. It was demonstrated that EXP, despite excelling in diminishing pain catastrophizing and perceived harmfulness of activities, was equally effective as GA in improving functional disability and main complaints, although the group difference almost reached statistical significance favouring EXP. Both treatment conditions did not differ in pain intensity and daily activity levels either. Nor was EXP superior to GA in the subgroup of highly fearful patients. Irrespective of treatment, approximately half the patients reported clinically relevant improvements in main complaints and functional disability, although for the latter outcome the group difference was almost significant favouring EXP. Furthermore, the effect of EXP relative to GA on functional disability and main complaints was mediated by decreases in catastrophizing and perceived harmfulness of activities. In sum, this study demonstrates that up to 6 months after treatment EXP is an effective treatment, but not more effective than GA, in moderately to highly fearful CLBP patients, although its superiority in altering pain catastrophizing and perceived harmfulness of activities is clearly established. Possible explanations for these findings are discussed.

Strength training in patients with myotonic dystrophy and hereditary motor and sensory neuropathy: A randomized clinical trial

A randomized clinical trial on the effects of strength training was performed in myotonic dystrophy (MyD) patients and patients with hereditary motor and sensory neuropathy (HMSN). Training and most measurement tools involved the proximal lower extremity muscles. The participants trained 3 times a week for 24 weeks with weights adapted to their force. Strength was evaluated by isokinetically measured knee torque. Fatiguability was assessed by the time an isometric contraction could be sustained. Functional performance was measured by timed motor performance and by questionnaires on functional performance. Serum myoglobin (Mb) levels were determined to detect changes in muscle fiber membrane permeability. The MyD group included 33 participants, and the HMSN group included 29 participants. Within each diagnostic group, patients were individually matched and subsequently randomized for treatment allocation. In the MyD patients, none of the measurement techniques showed any training effect. Neither were there signs of deterioration caused by the training. In the HMSN group, knee torques increased. Timed motor performance did not change, although the questionnaires showed an improvement on items related to upper-leg function. Mb levels did not change significantly as a result of the training. In conclusion, the MyD group showed neither positive nor negative effects of the training protocol, whereas the training produced a moderate increase in strength and leg-related functional performance in the HMSN group.

Treatment of complex regional pain syndrome type I.

Reflex sympathetic dystrophy (RSD), also known as complex regional pain syndrome type I (CRPS I), is a disabling neuropathic pain syndrome. Controversy exists about the effectiveness of therapeutic interventions for the management of RSD/CRPS I. In order to ascertain appropriate therapies we conducted a review of existing randomized controlled trials of therapies for this disabling disease. Eligible trials were identified from the Cochrane, Pubmed, Embase and MEDLINE databases from 1966 through June 2000, from references in retrieved reports and from references in review articles. Twenty‐six studies concerning treatment modalities were identified. Eighteen studies were randomized placebo‐controlled trials and eight studies were randomized active‐controlled trials. Three independent investigators reviewed articles for inclusion criteria using a 15‐item checklist. Seventeen of the trials were of high quality according to the 15‐item criteria. There was limited evidence for the effectiveness of these interventions because of the heterogeneity of treatment modalities. The search for trials concerning prevention of RSD/CRPS I resulted in two eligible studies. Both were of high quality and dealt with different interventions. There is limited evidence for their preventive effect.

Return-to-work interventions for low back pain: a descriptive review of contents and concepts of working mechanisms.

AbstractLow back pain is a major medical and social problem associated with disability, work absenteeism and high costs. Given the impact of the problem, there is a need for effective treatment interventions in occupational healthcare that aim at the prevention of chronic disability and the realisation of return to work. These so-called return-to-work (RTW)interventions are becoming increasingly popular. As well as questions concerning the effectiveness of RTW interventions, there are also important questions on the actual content and underlying concepts of these multifactorial intervention strategies.The purpose of this review is to examine the literature on the content and underlying concepts of RTW interventions for low back pain. Asystematic literature search identified 14 randomised controlled trials (RCTs) evaluating the effects of 19 RTW interventions. The content and concepts of these RTW interventions are described, compared and discussed in this review. Further, the contents of the RTW interventions are classified by the use of predefined components (physical exercises, education, behavioural treatments and ergonomic measures).The identified RTW interventions varied with respect to the disciplines involved, the target population and the number and duration of sessions. The classification showed that physical exercises were a component of most of the selected interventions, followed by education, behavioural treatments and ergonomic measures. The most prevalent combination of components was the combination of physical exercises, behavioural treatment and education. However, the types of physical exercises, behavioural treatment and education varied widely among the RTW interventions.The described concepts for the physical exercises were an increase of muscle strength, coordination, range of motion of the spine and cardiovascular fitness, and a decrease of muscle tension. Education as a part of RTW interventions is believed to increase the understanding of patients regarding their disorder and treatment. Behavioural treatments were mainly based on the gate control theory of pain (psychophysiological processes are involved in pain perception) and/or the operant conditioning hypothesis (pain behaviour is determined by its consequences). No concepts were described for ergonomic measures.Finally, the plausibility of the described concepts is discussed. Future RCTs on this topic should evaluate the underlying concepts of the RTW intervention in addition to its effectiveness.

Efficacy of Traction for Nonspecific Low Back Pain: 12-week and 6-month Results of a Randomized Clinical Trial

Study Design. A randomized clinical trial. Objectives. To assess the efficacy of motorized continuous traction for low back pain. Summary of Background Data. The available studies on the efficacy of lumbar traction do not allow clear conclusions because of severe methodologic flaws. The current trial aimed to overcome these shortcomings. Methods. Patients with at least 6 weeks of nonspecific low back pain were selected. High‐dose traction was compared with sham (or low‐dose) traction. Sham traction was given with a specially developed brace that becomes tighter in the back during traction. This was experienced as if real traction were exerted. The patients and the outcome assessor were unaware of treatment allocation. Outcome measures were: patients global perceived effect, severity of main complaints, functional status, pain, range of motion, work absence, and medical treatment. Results for the outcome measures at 12 weeks and 6 months after randomization are presented. Results. One hundred and fifty‐one patients were randomly allocated to one of the two treatment methods. Intention‐to‐treat analysis of the 12‐week and 6‐month results showed no statistically significant differences between the groups on all outcome measures; all 95% confidence intervals included the value zero. The number of patients lost to follow‐up study was very low. Other analyses showed the same results. Conclusions. Most common flaws of earlier studies on traction therapy could be overcome. This trial did not support the claim that traction is efficacious for patients with low back pain.

The Effects of a Graded Activity Intervention for Low Back Pain in Occupational Health on Sick Leave, Functional Status and Pain: 12-Month Results of a Randomized Controlled Trial

Introduction: Behaviorally oriented graded activity interventions have been suggested for sick-listed workers with low back pain on return to work, but have not been extensively evaluated. Methods: One hundred and thirty-four workers were randomly assigned to either a graded activity intervention (n = 67) or usual care (n = 67) and followed-up for 12 months. Results: The graded activity group returned back to work faster with a median of 54 days compared to 67 days in the usual care group. The graded activity intervention was more effective after approximately 50 days post-randomization (HRR = 1.9, CI = 1.2–3.1, p = 0.01). Differences between the groups in number of recurrent episodes, total number of days of sick leave due to low back pain, and total number of days of sick leave due to all diagnoses, were in favor of the graded activity group, although not statistically significant. No effects of the graded activity intervention were found for functional status or pain. Conclusion: Graded activity intervention is a valuable strategy to enhance short-term return to work outcomes.

Measures of function in low back pain/disorders: Low Back Pain Rating Scale (LBPRS), Oswestry Disability Index (ODI), Progressive Isoinertial Lifting Evaluation (PILE), Quebec Back Pain Disability Scale (QBPDS), and Roland-Morris Disability Questionnaire (RDQ).

Treatment of patients with chronic low back pain and its evolving disability primarily tries to improve the patients’ levels of activities and participation. Mostly, self-reported questionnaires have been used for clinical as well as research purposes to assess daily functioning (1,2), of which the most commonly used will be discussed below. However, this information may not necessarily reflect the real capacity of a patient’s performance. A recent review showed that the correlation of self-reported disability and physical activity level was at best moderate for patients with chronic low back pain (3). In order to improve objectivity, measures of body function, e.g., spinal mobility and lumbar extensor muscle strength, have been used, although the correlation with the level of disability is very weak (4,5). Furthermore, there are major concerns about reliability and validity (6–8). Besides the self-reported disability measures, many have urged to use more objective and direct measures of low back pain–specific functional capacity (5,9,10). Capacity is defined as the highest probable level of functioning that a person may reach in an activity domain at any given moment in a standardized environment. Although there is still no consensus for the definition of functional capacity evaluation (FCE), in the past decades, several FCE measures have been developed, of which the Isernhagen Work Systems Functional Capacity Evaluation (IWS-FCE) is among the most frequently used (11,12). However, recently published psychometric data have shown that some of the tasks included in the IWS-FCE are not reliable (13,14). Unfortunately, the entire sequence of tasks in, for example, the IWS-FCE, is time consuming and expensive, as is the training of the test observer. Therefore, we have decided not to include these measures in this review. Nevertheless, in order to keep up with, for example, the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations to evaluate several core outcome domains, including physical functioning (9), we wanted to include easy to use performance tasks. Several tasks have been described (8,15–17), but most of them are not low back pain specific, and some, such as the Back Performance Scale, show insufficient factor structure, as in this measure the quality of the performance is also scored (1,18). Therefore, we decided only to include a performance task that assesses lifting, an activity that specifically might be hampered by low back pain. For the selection of the self-reported disability questionnaires and lifting performance tasks, we only selected questionnaires/tests that are low back pain specific and of which all psychometric, including responsiveness, properties have been studied in relevant low back pain populations and published in peer-reviewed journals. Other criteria for selection were: being available in at least English and for performance task measures, easy to administer, inexpensive, and not time consuming when used in clinical practice.

Assessment of physical activity in daily life in patients with musculoskeletal pain

Patients with musculoskeletal pain often report limitations in daily functioning due to pain. Recently, the World Health Organisation (WHO) recommended in their International Classification of Functioning, Disability and Health (ICF) to accentuate patients remaining possibilities in functioning instead of focussing on restrictions. In patients with musculoskeletal pain, this would imply that a persons “daily activity level” rather than his/her “disability level” has to be focussed upon. At this moment, broad consensus about how to measure physical activity in daily life in patients with pain has not been established. The objectives of this study were twofold, firstly to identify instruments assessing the level of physical activity in daily life in patients with musculoskeletal pain and secondly to review psychometric properties of the instruments identified. In all, 42 articles derived from the literature on musculoskeletal pain were included in the review. Thirty four assessment instruments for physical activity were identified; fourteen questionnaires, ten diaries and ten instruments based on movement registration. Only, 10 out of these 34 instruments contained full or partial information regarding pain specific psychometric properties. At this moment, for quantitative assessment of physical activity, movement registration seems to be favoured based on its higher degree of objectivity in comparison with self report. Taken together more research is needed to evaluate psychometric properties of instruments measuring physical activity in musculoskeletal pain.

Pain reducing effect of three types of transcutaneous electrical nerve stimulation in patients with chronic pain: a randomized crossover trial

&NA; Transcutaneous electrical nerve stimulation (TENS) is a frequently applied therapy in chronic pain although evidence for effectiveness is inconclusive. Several types of TENS, based on different combinations of frequency, pulse duration and intensity, exist. The precise mechanism of action and the relevance of combinations of stimulus parameters are still unclear. To compare the effectiveness of three types of TENS we conducted a randomized, single blinded crossover trial. Patients received two times a 2‐week period of daily TENS treatment, separated by a washout period of 2 weeks. In total, 180 chronic pain patients were randomized into three groups. In group 1, high frequency, low intensity TENS (HFT) was compared with high frequency, high intensity TENS (HIT). In groups 2 and 3, HFT and HIT were compared with a control TENS (COT). The order of applying the different modalities of TENS in each group was also randomized. Primary outcome was the patients overall assessment of effectiveness and pain reduction (VAS). No differences were found in patients assessment or pain reducing effect between the three groups, indicating no superiority of one type of TENS. In total, 56% continued TENS after the 2‐week treatment period. At 6 months, 42% of all patients still used TENS. We concluded that there were no differences in effectiveness for the three types of TENS used in this study. Because no placebo group was included, no definite conclusions on effectiveness of TENS in general in the treatment of chronic pain could be made.

Extensive Validation of the Pain Disability Index in 3 Groups of Patients With Musculoskeletal Pain

Study Design. A cross-sectional study design was performed. Objective. To validate the pain disability index (PDI) extensively in 3 groups of patients with musculoskeletal pain. Summary of Background Data. The PDI is a widely used and studied instrument for disability related to various pain syndromes, although there is conflicting evidence concerning factor structure, test-retest reliability, and missing items. Additionally, an official translation of the Dutch language version has never been performed. Methods. For reliability, internal consistency, factor structure, test-retest reliability and measurement error were calculated. Validity was tested with hypothesized correlations with pain intensity, kinesiophobia, Rand-36 subscales, Depression, Roland-Morris Disability Questionnaire, Quality of Life, and Work Status. Structural validity was tested with independent backward translation and approval from the original authors. Results. One hundred seventy-eight patients with acute back pain, 425 patients with chronic low back pain and 365 with widespread pain were included. Internal consistency of the PDI was good. One factor was identified with factor analyses. Test-retest reliability was good for the PDI (intraclass correlation coefficient, 0.76). Standard error of measurement was 6.5 points and smallest detectable change was 17.9 points. Little correlations between the PDI were observed with kinesiophobia and depression, fair correlations with pain intensity, work status, and vitality and moderate correlations with the Rand-36 subscales and the Roland-Morris Disability Questionnaire. Conclusion. The PDI-Dutch language version is internally consistent as a 1-factor structure, and test-retest reliable. Missing items seem high in sexual and professional items. Using the PDI as a 2-factor questionnaire has no additional value and is unreliable.