Emmanuel Coudeyre

General practitioners' fear-avoidance beliefs influence their management of patients with low back pain

Abstract The objectives of this cross‐sectional study conducted in primary care practice in France were to describe general practitioners’ (GPs) fear‐avoidance beliefs about low back pain (LBP), investigate the impact of these beliefs on their following guidelines for bed rest, physical activities, and sick leave, and uncover factors associated with GPs’ fear‐avoidance beliefs. A total of 864 GPs completed a 5‐part self‐administered questionnaire. Parts 1, 2, and 3 concerned demographic, professional data, and personal history of back pain, respectively. Part 4 dealt with GPs’ education about LBP and practice for LBP. Part 5 assessed GPs’ fear‐avoidance beliefs on the Fear‐Avoidance Beliefs Questionnaire (FABQ). GPs’ mean age was 48.2 ± 7.0 years, 80% were male, 88% had been practicing for more than 10 years, and 52% reported a previous personal episode of acute LBP. Forty‐six percent had participated in an educational session on LBP during the last 3 years. Mean scores for the FABQ Phys and Work were 9.6 ± 4.8 and 17.5 ± 6.7, respectively. Sixteen percent of participants had high rating on the FABQ Phys (FABQ Phys score > 14). FABQ Phys score was associated with recommendation of bed rest or rest during sick leave (p < 0.0001) for acute LBP and less advice to maintain maximum bearable physical activities (p < 0.001) for chronic LBP. FABQ Work score was associated with prescribing sick leave during painful periods (p < 0.005) for acute LBP and less advice to maintain maximum bearable physical activities (p < 0.001) for chronic LBP. GPs’ fear‐avoidance beliefs about LBP negatively influence their following guidelines concerning physical and occupational activities for patients with LBP.

Non-drug treatment (excluding surgery) in rheumatoid arthritis: Clinical practice guidelines

OBJECTIVES Because drugs do not halt joint destruction in rheumatoid arthritis (RA), non-drug treatments are an important adjunct to drug treatment. Establishing rules governing their use is difficult because treatment is multidisciplinary, complex, and difficult to assess. The aims of these guidelines were to (a) establish the indications for physical therapies and for educational, psychological, and other non-drug interventions, (b) address social welfare, occupational, and organizational issues. METHODS A systematic literature search (MEDLINE, EMBASE, CINAHL, Pascal, Cochrane Library, HTA database) (1985-2006) was completed with information obtained from specialty societies and the grey literature. A review of the studies meeting inclusion criteria, with evidence levels, was used by a multidisciplinary working group (18 experts) to draft guidelines. Consensus was reached when evidence was lacking on key topics. The draft guidelines were scored by 60 peer reviewers, amended when necessary, and then validated by the HAS Board. RESULTS Of the 1819 articles retrieved, 817 were analysed and 382 cited in the report. Low-power randomized clinical trials constituted the highest level of evidence. Grade B guidelines (intermediate evidence level) concerned aerobic activities, dynamic muscular strengthening, and therapeutic patient education. Grade C (low evidence level) concerned use of rest orthoses or assistive devices, balneotherapy and spa therapy, self-exercise programmes, and conventional physiotherapy. Professional agreement (no scientific evidence) was reached for orthotic insoles and footwear, chiropody care, thermotherapy, acupuncture, psychological support, occupational adjustments, and referral to social workers. CONCLUSION Aerobic activities, dynamic muscular reinforcement, and therapeutic patient education are valuable in non-drug management of RA.

Fear-avoidance beliefs about back pain in patients with subacute low back pain

Abstract The fear‐avoidance beliefs of patients with subacute low back pain (LBP) considered at risk for chronic disabling LBP are not well known. The objectives of this cross‐sectional descriptive survey, conducted in secondary care practice, were to assess fear‐avoidance beliefs about back pain in patients with subacute LBP and to seek an association between physician or patient characteristics and level of fear‐avoidance beliefs. A total of 286 rheumatologists completed a self‐administered questionnaire assessing physicians’ demographic, professional data, personal history of back pain, and back pain fear‐avoidance beliefs (on the Fear‐Avoidance Belief Questionnaire [FABQ]) and 443 patients with sLBP completed one on pain, perceived handicap and disability (Quebec Back Pain Disability Scale), anxiety and depression (Hospital Anxiety Depression questionnaire), and back pain beliefs (FABQ). Mean FABQ scores for rheumatologists for physical activities (FABQ Phys) and occupational activities (FABQ Work) were 9.2 ± 4.4 (range 0–21) and 16.7 ± 6.9 (range 2–37), respectively, and patient scores were 16.7 ± 5.2 and 19.3 ± 12.4, respectively. A total of 68% of patients and 10% of physicians had a high rating on the FABQ Phys (>14). Patients’ fear‐avoidance beliefs about physical activity were associated with low level of education (odds ratio [OR] 4.19; 95% confidence interval [CI] 1.83–9.57), patients’ perceived disability (OR 1.05; CI 1.03–1.07), and physicians’ high FABQ Phys score (OR 5.92; CI 1.31–26.32). Here we show that fear‐avoidance beliefs about back pain were high in patients with subacute LBP and their rheumatologists.

Adherence to, and results of, physical therapy programs in patients with hip or knee osteoarthritis. Development of French clinical practice guidelines.

OBJECTIVE To develop recommendations regarding adherence to physical therapy programs by patients with hip or knee osteoarthritis. METHODS We used the method recommended by the French Society for Physical and Rehabilitation Therapy (SOFMER), which combines a systematic literature review, a practice survey, and validation by a multidisciplinary panel of experts. RESULTS When setting up exercise programs for patients with lower limb osteoarthritis, measures should be taken to increase effectiveness by optimizing adherence. Patient selection is among these measures, as exercise programs are more likely to succeed in patients with a history of being physically active, a positive view of the suggested program, and/or favorable social and material conditions. Regardless of the type of exercise, the program should be tailored to exercise capacity and pain level (professional consensus). Patient adherence can be improved by explaining the expected results to the patient, asking the patient to keep a self-evaluation diary, conducting long-term evaluations (by phone or mail), and providing follow-up visits. CONCLUSION Studies of adherence according to the type of exercise are needed. The relevance of widely used incentives in patients with hip or knee osteoarthritis should be evaluated in new therapeutic trials.

Clinical practice guidelines for rest orthosis, knee sleeves, and unloading knee braces in knee osteoarthritis.

OBJECTIVE To develop clinical practice guidelines concerning the use of bracing--rest orthosis, knee sleeves and unloading knee braces--for knee osteoarthritis. METHODS The French Physical Medicine and Rehabilitation Society (SOFMER) methodology, associating a systematic literature review, collection of everyday clinical practice, and external review by multidisciplinary expert panel, was used. RESULTS Few high-level studies of bracing for knee osteoarthritis were found. No evidence exists for the effectiveness of rest orthosis. Evidence for knee sleeves suggests that they decrease pain in knee osteoarthritis, and their use is associated with subjective improvement. These actions do not appear to depend on a local thermal effect. The effectiveness of knee sleeves for disability is not demonstrated for knee osteoarthritis. Short- and mid-term follow-up indicates that valgus knee bracing decreases pain and disability in medial knee osteoarthritis, appears to be more effective than knee sleeves, and improves quality of life, knee proprioception, quadriceps strength, and gait symmetry, and decreases compressive loads in the medial femoro-tibial compartment. However, results of response to valgus knee bracing remain inconsistent; discomfort and side effects can result. Thrombophlebitis of the lower limbs has been reported with the braces. Braces, whatever kind, are infrequently prescribed in clinical practice for osteoarthritis of the lower limbs. CONCLUSION Modest evidence exists for the effectiveness of bracing--rest orthosis, knee sleeves and unloading knee braces--for knee osteoarthritis, with only low level recommendations for its use. Braces are prescribed infrequently in French clinical practice for osteoarthritis of the knee. Randomized clinical trials concerning bracing in knee osteoarthritis are still necessary.

Effect of a Simple Information Booklet on Pain Persistence after an Acute Episode of Low Back Pain: A Non-Randomized Trial in a Primary Care Setting

Objective Mass-media campaigns have been known to modify the outcome of low back pain (LBP). We assessed the impact on outcome of standardized written information on LBP given to patients with acute LBP. Methods Design: A 3-month pragmatic, multicenter controlled trial with geographic stratification. Setting: Primary care practice in France. Participants: 2752 patients with acute LBP. Intervention: An advice book on LBP (the “back book”). Main outcome measures: The main outcome measure was persistence of LBP three months after baseline evaluation. Results 2337 (85%) patients were assessed at follow-up and 12.4% of participants reported persistent LBP. The absolute risk reduction of reporting persistent back pain in the intervention group was 3.6% lower than in the control group (10.5% vs. 14.1%; 95% confidence interval [−6.3% ; −1.0%]; p value adjusted for cluster effect = 0.01). Patients in the intervention group were more satisfied than those in the control group with the information they received about physical activities, when to consult their physician, and how to prevent a new episode of LBP. However, the number of patients who had taken sick leave was similar, as was the mean sick-leave duration, in both arms, and, among patients with persistent pain at follow-up, the intervention and control groups did not differ in disability or fear-avoidance beliefs. Conclusions The level of improvement of an information booklet is modest, but the cost and complexity of the intervention is minimal. Therefore, the implications and generalizability of this intervention are substantial. Trial Registration ClinicalTrials.gov NCT00343057

The effects of music intervention in the management of chronic pain: a single-blind, randomized, controlled trial.

Objective:A music intervention method in the management of pain was recently developed while taking account of recommendations in the scientific literature. The objective of this study was to assess the usefulness of this music intervention to the management of patients with chronic pain. Methods:A controlled, single-blind, randomized trial was used. Eighty-seven patients presenting with lumbar pain, fibromyalgia, inflammatory disease, or neurological disease were included in the study. During their hospitalization, the intervention arm (n=44) received at least 2 daily sessions of music listening between D0 and D10, associated with their standard treatment, and then pursued the music intervention at home until D60 using a multimedia player in which the music listening software program had been installed. The control arm received standard treatment only (n=43). The end points measured at D0, D10, D60, and D90 were: pain (VAS), anxiety-depression (HAD) and the consumption of medication. Results:At D60 in the music intervention arm, this technique enabled a more significant reduction (P<0.001) in pain (6.3±1.7 at D0 vs. 3±1.7 at D60) when compared with the arm without music intervention (6.2±1.5 at D0 vs. 4.6±1.7 at D60). In addition, music intervention contributed to significantly reducing both anxiety/depression and the consumption of anxiolytic agents. Discussion:These results confirm the value of music intervention to the management of chronic pain and anxiety/depression. This music intervention method appears to be useful in managing chronic pain as it enables a significant reduction in the consumption of medication.

Animal evidence for hyaluronic acid efficacy in knee trauma injuries. Review of animal-model studies

INTRODUCTION Intra-articular injections of hyaluronic acid (HA) could have potential interest in therapy of acute knee trauma injuries, but few results are available in humans. OBJECTIVE We reviewed the literature for animal studies of intra-articular HA injections after knee trauma injury to determine the interest of human clinical research into and/or use of such injections for knee trauma. METHODS Systematic literature search on MEDLINE for studies involving animal models of osteoarthritis created by acute knee trauma injury, with HA injections beginning during the 2 weeks after injury. RESULTS The search revealed 14 studies with a high methodological quality: 7 related to meniscus injury, 3 ACL injury, 1 combined ACL-meniscus injury and 3 cartilage injury. The animal models were rabbits in 10 studies. Four studies demonstrated positive effects and 3 moderate effects of intra-articular HA injection for meniscus injury; 1 positive effects and 2 no effect for ACL injury; 1 positive effects for combined ACL-meniscus injury; and 2 moderate effects and 1 no effect for cartilage injury. CONCLUSIONS With a high strength of recommendation, intra-articular HA injections in animal models with meniscus injury improved the healing process and/or had a protective role in articular cartilage, a slightly protective role in ACL injury animal models and low or no effect on healing in articular cartilage injury animal models.

Usefulness of taping in lower limb osteoarthritis. French clinical practice guidelines

OBJECTIVES To develop clinical practice guidelines about the use of taping in the management of lower limb osteoarthritis. METHOD We used the methodology advocated by the SOFMER (French Society for Physical and Rehabilitation Medicine), which combines a literature review, collection of data on current practice patterns, and validation of the recommendations by a multidisciplinary panel of experts. Our evaluation focused on the effectiveness of taping in relieving symptoms of lower limb osteoarthritis. RESULTS Ankle taping for osteoarthritis is not recommended, given the absence of published data and very low level of use in France. Few studies are available on knee taping for osteoarthritis. CONCLUSIONS Published studies exhibit a number of methodological weaknesses. There is no strong evidence that taping is effective in knee osteoarthritis, and this treatment modality is rarely used in France. Therefore, there is no strong basis at present for recommending taping as part of the management of knee osteoarthritis. Well-designed studies of patellar taping to modify the relationships between the patellar and the trochlea are desirable to determine whether this treatment modality benefits patients with knee osteoarthritis, most notably those with involvement of the femoropatellar compartment.

Orthèses plantaires et gonarthrose : évaluation des effets biomécaniques et cliniques à partir d'une revue de la littérature

OBJECTIVE To determine the biomechanical and clinical effectiveness of foot insoles in patients with knee osteoarthritis. MATERIALS AND METHODS A systematic review of the literature (Medline, Pascal and Embase) using the MESH words knee, and insole and plantar orthosis for the biomechanical part and osteoarthritis, and insole and plantar orthosis for the clinical part. Clinical studies were classified by 2 independent readers using the Jadad scale. RESULTS Two biomechanical theories were found: the adduction moment theory, which explains the effect of heel wedging, and articular chain theory, which explains the effect of lateral wedged insoles. The clinical effect was explained more by an anti-algesic effect than an anatomic or functional effect: the treated group consumed fewer nonsteroidal anti-inflammatory drugs than the placebo group for up to 2-years of treatment. Evidence is lacking because of methodological weakness and few clinical trials. The information on side effects is limited. DISCUSSION Laterally wedged foot insoles are proposed for the treatment of knee medial compartment osteoarthritis. The clinical effect is probably limited, but the treatment may reduce the digestive and renal side effects of prolonged use of nonsteroidal anti-inflammatory drugs. Foot insoles could be recommended in clinical practice despite the lack of evidence in comparing the effectiveness of other therapeutics in knee osteoarthritis. CONCLUSION Use of foot insoles is a nonpharmacologic treatment of osteoarthritis of the knee medial compartment.