Eva Neubauer

HKF-R 10 - screening for predicting chronicity in acute low back pain (LBP): a prospective clinical trial.

Study design Prospective cohort study.

Therapy outcome after multidisciplinary treatment for chronic neck and chronic low back pain: a prospective clinical study in 365 patients

Objectives: This prospective longitudinal clinical study analyses the therapy outcome of 365 patients with either chronic neck (n = 134) or low back (n = 231) pain treated with a multidisciplinary biopsychosocial therapy approach. Methods: Patients with chronic neck pain (NP) or low back pain (LBP) for 3 months or longer, corresponding sick leave for longer than 6 weeks, and clearly defined inclusion and exclusion criteria underwent a 3‐week standardized inpatient multidisciplinary biopsychosocial therapy. Baseline sociodemographic, occupational, functional, and psychological data at entry into the study (T0) were comparable in both groups. At the 6‐month follow‐up (T1), five different therapy outcomes were analysed in both groups: back‐to‐work status, generic health status (the 36‐item Short Form Health Survey, SF‐36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy. Results: Both treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back‐to‐work rate was 67.4%. At the final follow‐up there were no significant differences between the group with chronic NP and the group with chronic LBP in the outcome criteria back‐to‐work status, improvement of health status and functional capacity, satisfaction with therapy, and reduction of pain. Conclusion: Evaluation of the main results of this study suggests that patients with chronic NP also derive significant benefit from a multidisciplinary treatment strategy, demonstrated in the literature so far mainly for patients with chronic LBP.

The influence of the grade of chronicity on the outcome of multidisciplinary therapy for chronic low back pain.

Study Design. Prospective longitudinal clinical study. Objective. The objective of the study was to analyze the outcome of different stages of chronicity in patients with chronic low back pain treated with a multidisciplinary therapy. Summary of Background Data. Results of studies comparing different grades of chronicity in therapy for chronic low back pain have not been published so far. Methods. A total of 387 patients with chronic low back pain for 3 months or longer and a corresponding sick leave for longer than 6 weeks underwent a 3-week standardized multidisciplinary therapy. At baseline (T0), patients were assigned into 3 groups of chronicity grades according to the classification of von Korff et al (Group A, Grades I and II; Group B, Grade III; Group C, Grade IV) and were prospectively followed. At the the 6-month follow-up (T1), 5 different therapy outcomes were analyzed and compared in the 3 groups: back-to-work status, generic health status (SF-36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy. Results. At T0, patients in Group C had a higher pain level, a longer history of pain, and more general and more psychosomatic comorbidities than patients with lower levels of chronicity. All 3 treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back-to-work rate was 67.4%. At the final follow-up, there were significantly better results in terms of functional capacity and pain level in patients with lower grades of chronicity but mostly due also to worse initial baseline values. Back-to-work rate, satisfaction with therapy, and the Mental Component Summary of the SF-36 did not show a significant difference at T1 between the groups analyzed. Conclusion. According to the results of this study, patients with chronic low back pain also derive significant benefit from a multidisciplinary treatment strategy in higher stages of chronicity. Therefore, therapy should not be limited to the patients in lower stages of chronicity.

Efficacy of Multidisciplinary Treatment for Patients With Chronic Low Back Pain A Prospective Clinical Study in 395 Patients

BackgroundThe effectiveness of multidisciplinary treatment programs varies throughout the literature, and it remains controversial how therapy outcome is affected by patients’ individual parameters and which treatment settings work best. ObjectivesWe set out to examine the impact of patient variables on the effectiveness of a 3-week multidisciplinary treatment program in patients with chronic low back pain. By presenting effect sizes, we aimed to enable the comparison of our findings with other studies across disciplines. MethodsData on 395 patients were prospectively collected at study entry, at the end of the program (T1) and after 6 months’ follow-up (T2). Relevant therapy outcomes were analyzed by presenting effect sizes with Cohen’s d. Group comparisons were performed for sociodemographic and clinical features to determine the impact on therapy outcome. ResultsMedium effect sizes (d = −0.6 to −0.7) were shown for visual analog scale (VAS) after treatment and at T2, indicating clinically relevant pain relief. Significant changes in pain-related disability were observed immediately at T1 with a strong treatment effect (d = 0.8). Functional capacity was improved with low to medium effect sizes (0.4–0.5). Quality-of-life subscales (36-item Short Form Health Survey) improved significantly at T1 for physical function, vitality, and mental health (d = 0.5–0.8). Center for Epidemiological Studies – Depression Scale scores improved significantly with strong effect sizes of d = 0.7. Sociodemographic parameters displayed a significant impact on effect sizes for visual analog scale at T2, with females (d = −0.9), age group 30 to 39 years (d = −1), and patients with low physical job exposure (d = −0.9) benefiting most. An increase in number of pain locations (−0.7) and severity of accompanying pain (−0.7) in other body areas significantly impaired therapy outcome and effect sizes of VAS. ConclusionsThus, multidisciplinary treatment ameliorates pain, functional restoration, and quality of life with medium to high effect sizes even for patients with a long history of chronic back pain. Effect sizes are higher than for monodisciplinary treatments and treatment effects remained stable at 6-month follow-up in a longitudinal uncontrolled study design. Thus, we believe that multidisciplinary treatment is vital for the treatment of patients with chronic low back pain. The impact of sociodemographic and pain-related parameters needs to be taken into account when including patients in an appropriate treatment program. We emphasize the presentation of effect sizes as a vital treatment evaluation to enable cross-sectional comparison of therapy outcomes.

The impact of pain spread on the outcome of multidisciplinary therapy in patients with chronic musculoskeletal pain – A prospective clinical study in 389 patients

Background: Musculoskeletal pain represents a continuous process ranging from single‐site to multiple‐site pain, with an increase in pain sites accompanied by an increasing risk of chronification and the development of further comorbidities. Within this context, the impact of pain spread on therapy outcome is still unknown.

Attachment, Symptom Severity, and Depression in Medically Unexplained Musculoskeletal Pain and Osteoarthritis: A Cross-Sectional Study

Background Attachment insecurity relates to the onset and course of chronic pain via dysfunctional reactions to pain. However, few studies have investigated the proportion of insecure attachment styles in different pain conditions, and results regarding associations between attachment, pain severity, and disability in chronic pain are inconsistent. This study aims to clarify the relationships between insecure attachment and occurrence or severity of chronic pain with and without clearly defined organic cause. To detect potential differences in the importance of global and romantic attachment representations, we included both concepts in our study. Methods 85 patients with medically unexplained musculoskeletal pain (UMP) and 89 patients with joint pain from osteoarthritis (OA) completed self-report measures of global and romantic attachment, pain intensity, physical functioning, and depression. Results Patients reporting global insecure attachment representations were more likely to suffer from medically unexplained musculoskeletal pain (OR 3.4), compared to securely attached patients. Romantic attachment did not differ between pain conditions. Pain intensity was associated with romantic attachment anxiety, and this relationship was more pronounced in the OA group compared to the UMP group. Both global and romantic attachment anxiety predicted depression, accounting for 15% and 17% of the variance, respectively. Disability was independent from attachment patterns. Conclusions Our results indicate that global insecure attachment is associated with the experience of medically unexplained musculoskeletal pain, but not with osteoarthritis. In contrast, insecure attachment patterns seem to be linked to pain intensity and pain-related depression in unexplained musculoskeletal pain and in osteoarthritis. These findings suggest that relationship-informed focused treatment strategies may alleviate pain severity and psychological distress in chronic pain independent of underlying pathology.

Internet-Based Aftercare for Patients with Back Pain—A Pilot Study

OBJECTIVE In order to maintain treatment gains achieved during multidisciplinary treatments for chronic back pain, patients are challenged to implement the behavioral changes they learned during treatment into their daily life. Offering support during the critical time after treatment conclusion helps patients deal with relapses, provides them with practical advice and social support, and helps to master this transfer. As in-person offerings are not always feasible, innovative concepts are needed to enable hospitals to provide aftercare to their patients. SUBJECTS AND METHODS An Internet-based aftercare intervention following multidisciplinary therapy for back pain was constructed, implemented, and evaluated. The aftercare program comprised two modules: (1) an individualized self-monitoring module and (2) a weekly, 90-min chat session moderated by a therapist whom participants already knew from treatment. A randomized controlled trial (n=75) was conducted that compared the post-treatment symptom developments of program participants with symptom developments of controls (treatment as usual [TAU]). RESULTS The program was proven to be feasible and well accepted by participants; on average, 68.2% of the participants rated the previous chat session as helpful. Intention-to-treat analyses demonstrated significant effects on post-treatment courses of disability. The largest effects were found for pain-related disability: for TAU participants, disability increased an average of 1.25 scale points (Roland-Morris Questionnaire) per 100 days; for program participants, disability decreased an average of 0.39 scale points (p<0.01). CONCLUSIONS The aftercare intervention was shown to be feasible and well accepted. Its efficacy should be tested with a larger-scale randomized controlled trial.

Wirksamkeit eines Internet-gestützten Nachsorgeangebots für Patienten mit chronischen Rückenschmerzen

Chronic back pain leads to high societal costs and severely decreased quality of life for the sufferers. Pain treatment aims at sustainable behaviour changes in order to positively affect pain development in the medium term. A multicenter, randomised control trial was conducted. Participants (N=334) were recruited at 6 German hospitals and randomly assigned to an Internet-based aftercare intervention or treatment-as-usual. Primary endpoint was 12 months after treatment termination, primary outcome was pain intensity, and secondary outcomes were physical functioning, quality of life, and ability to work.The intervention was well accepted by the participants. Its efficacy could not be demonstrated. Neither pain intensity nor the secondary outcomes differed between the 2 study groups.Possible reasons for disappointing efficacy and preconditions for Internet-based programs will be discussed.

Predicting Persistent Back Symptoms by Psychosocial Risk Factors: Validity Criteria for the ÖMPSQ and the HKF-R 10 in Germany.

Objective 10% of all individuals in Germany develop persistent symptoms due to nonspecific back pain (NSBP) causing up to 90% of direct and indirect expenses for health care systems. Evidence indicates a strong relationship between chronic nonspecific back pain and psychosocial risk factors. The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) and the German Heidelberger Kurzfragebogen Rückenschmerz (HKF-R 10) are deemed valid in prediction of persistent pain, functional loss or amount of sick leave. This study provides and discusses validity criteria for these questionnaires using ROC-curve analyses. Quality measurements included sensitivity and specificity, likelihood-ratio related test-efficiencies and clinical utility in regard to predictive values. Methods 265 patients recruited from primary and secondary care units completed both questionnaires during the same timeframe. From the total, 133 patients returned a 6-month follow-up questionnaire to assess the validity criteria for outcomes of pain, function and sick leave. Results Based on heterogeneous cut-offs for the ÖMPSQ, sensitivity and specificity were moderate for outcome of pain (72%/75%). Very high sensitivity was observed for function (97%/57%) and high specificity for sick leave (63%/85%). The latter also applied to the HKF-R 10 (pain 50%/84%). Proportions between sensitivity and specificity were unbalanced except for the ÖMPSQ outcome of pain. Likelihood-ratios and positive predictive values ranged from low to moderate. Conclusion Although the ÖMPSQ may be considered useful in identification of long-term functional loss or pain, over- and underestimation of patients at risk of chronic noncspecific back pain led to limited test-efficiencies and clinical utility for both questionnaires. Further studies are required to quantify the predictive validity of both questionnaires in Germany.

The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy

Abstract Objectives Little is known about the affected cognitive problems in chronic low back pain patients. For this patient cohort research mostly focused on memory of pain, rather than cognitive difficulties related to pain. Chronic pain may be associated with specific (yet undefined) cognitive deficits that affect everyday behaviour. We set out to compare the cognitive function of patients with chronic low back pain (cLBP) in the course of multidisciplinary pain treatments before and after therapy. Methods Thirty-three patients with cLBP and 25 healthy controls between 20 and 70 years were recruited into the study. The inclusion criteria for patients were: (1) a history of at least 12 weeks of chronic myofascial low back pain without radicular pain sensation before enrolment; (2) grade II and higher chronicity according to von Korff; (3) no opioid medication. The patients recruited had a mean pain duration of 7.13 ± 7.16 years and reported a mean pain intensity of 6.62 ± 2.04 (visual analogue score, VAS). Their mean back function according to the Funktionsfragebogen Hannover (FFbH, a questionnaire comparable with the Health Assessment Questionnaire) was 52.39 ± 20.23%. At three time points (before therapy, 3 weeks and 6 months after therapy) the study subjects were assessed prospectively with a battery of visual memory tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB). These included choice reaction time (CRT), pattern recognition memory (PRM) and spatial span (SSP). In parallel, the Trail-Making Test (TMT-A, TMT-B) and the Wechsler Adult Intelligence Scale (WAIS-III) were used to evaluate intelligence and cognitive flexibility. Results At the beginning of MDPT (T1), it took patients with cLBP significantly longer than HC to complete TMT-A (38.29 ± 19.99 s vs 30.25 ± 14.19 s, p = 0.047) and TMT-B (72.10 ± 26.98 s vs 55.99 ± 22.14 s, p = 0.034). There were no significant differences between patients and HC in CRT, PRM and SSP. Three weeks (T2) and 6 months (T3) after MDPT, TMT-A reaction time of patients significantly improved by 6.5 s and 8.1 ms (38.3 ±19.9 s vs 31.8 ±12.3 s, p = 0.02 and 31.8 ± 12.3 s vs 30.2 ± 8.9 s, p = 0.021, respectively). The patients’ working memory was also better 6 months after MDPT (48.8 ± 11.1% at T1, 51.2 ±11.9% at T2, 57.1 ±10.9% at T3, p = 0.008). Significant correlations among pain, depression/anxiety, medication and neuropsychological tests were found. Conclusions These findings show that patients with cLBP have slowed speeds of information processing and working memory, but no alteration in attention and recognition memory. There are clearly interactions of cognitive function with pain, depression, anxiety, and medication. MDPT may improve the impaired cognitive function of patients with cLBP. Implication Health professionals should contemplate the results from this study when planning therapy strategies especially when prescribing pain medications such opioids to patients with chronic low back pain.