Eva Rasmussen-Barr

Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain.

The present aim was to compare the effects of stabilizing training with those of manual treatment in patients with sub-acute or chronic low-back pain (LBP). Forty-seven patients were randomized to a stabilizing training group (ST group) or a manual treatment group (MT group). The patients underwent a 6-week treatment programme on a weekly basis. Pain, health and functional disability level at the start of treatment, after treatment, and at 3- and 12-month follow-ups were assessed. In the ST group all assessed variables improved significantly (P<0.05) after the treatment period and were maintained long term. After the treatment period there was a significant difference between the groups in assessed function (P<0.05). More individuals in the ST group had improved than in the MT group. At the 3-month follow-up significantly more improved individuals were evident in the ST group regarding pain, general health and functional disability levels. In the long term, significantly more (P<0.05) patients in the MT group reported recurrent treatment periods. The study did not indicate any clear short-term differences between the groups in the accessed outcome measures. In the long term, however, stabilizing training seemed to be more effective than manual treatment in terms of improvement of individuals and the reduced need for recurrent treatment periods.

The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review

BACKGROUND CONTEXT Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP). PURPOSE The purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP. DESIGN/SETTING The design of this study was a systematic review. METHODS In October 2011, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. To ensure the completeness of the search, a hand search and a search of bibliographies was conducted and all relevant references included. A total of 2,031 references were retrieved, leaving 566 references after the removal of duplicates. For 53 references, the full-text was assessed and, finally, 21 studies were included in the analysis. RESULTS The most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks-3 months of LBP). Four cohort studies, conducted by disability insurance companies in the United States, Canada, and Belgium, included 258 to 1,068 patients mostly with nonspecific LBP. These researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. The odds ratio (OR) ranged from 1.05 (95% confidence interval [CI] 1.02-1.09) to 4.64 (95% CI, 1.57-13.71). The highest OR was found when applying a high cutoff for FABQ Work subscale scores. This may indicate that the use of cutoff values increases the likelihood of positive findings. This issue requires further study. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive. CONCLUSIONS Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.

Fear-avoidance beliefs—a moderator of treatment efficacy in patients with low back pain: a systematic review

BACKGROUND CONTEXT Psychological factors are believed to influence the development of chronic low back pain. To date, it is not known how fear-avoidance beliefs (FABs) influence the treatment efficacy in low back pain. PURPOSE To summarize the evidence examining the influence of FABs measured with the Fear-Avoidance Belief Questionnaire or the Tampa Scale of Kinesiophobia on treatment outcomes in patients with low back pain. STUDY DESIGN/SETTING This is a systematic review. PATIENT SAMPLE Patients with low back pain. OUTCOME MEASURES Work-related outcomes and perceived measures including return to work, pain, and disability. METHODS In January 2013, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. A hand search of the six most often retrieved journals and a bibliography search completed the search. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS research studies that included patients with low back pain who participated in randomized controlled trials (RCTs) investigating nonoperative treatment efficacy. Out of 646 records, 78 articles were assessed in full text and 17 RCTs were included. Study quality was high in five studies and moderate in 12 studies. RESULTS In patients with low back pain of up to 6 months duration, high FABs were associated with more pain and/or disability (4 RCTs) and less return to work (3 RCTs) (GRADE high-quality evidence, 831 patients vs. 322 in nonpredictive studies). A decrease in FAB values during treatment was associated with less pain and disability at follow-up (GRADE moderate evidence, 2 RCTs with moderate quality, 242 patients). Interventions that addressed FABs were more effective than control groups based on biomedical concepts (GRADE moderate evidence, 1,051 vs. 227 patients in studies without moderating effects). In chronic patients with LBP, the findings were less consistent. Two studies found baseline FABs to be associated with more pain and disability and less return to work (339 patients), whereas 3 others (832 patients) found none (GRADE low evidence). Heterogeneity of the studies impeded a pooling of the results. CONCLUSIONS Evidence suggests that FABs are associated with poor treatment outcome in patients with LBP of less than 6 months, and thus early treatment, including interventions to reduce FABs, may avoid delayed recovery and chronicity. Patients with high FABs are more likely to improve when FABs are addressed in treatments than when these beliefs are ignored, and treatment strategies should be modified if FABs are present.

Graded Exercise for Recurrent Low-Back Pain : A Randomized, Controlled Trial With 6-, 12-, and 36-Month Follow-ups

Study Design. The study was a randomized controlled trial. Treatment was for 8 weeks, with follow-up posttreatment and at 6-, 12-, and 36- months. Objective. The purpose was to evaluate the effect of a graded exercise intervention emphasizing stabilizing exercises in patients with nonspecific, recurrent low back pain (LBP). Summary of Background Data. Exercise therapy is recommended and widely used as treatment for LBP. Although stabilizing exercises are reportedly effective in the management of certain subgroups of LBP, such intervention protocols have not yet been evaluated in relation to a more general exercise regimen in patients with recurrent LBP, all at work. Methods. Seventy-one patients recruited consecutively (36 men, 35 women) with recurrent nonspecific LBP seeking care at an outpatient physiotherapy clinic were randomized into 2 treatment groups; graded exercise intervention or daily walks. The primary outcome was perceived disability and pain at 12-month follow-up. Secondary outcomes included physical health, fear-avoidance, and self-efficacy beliefs. Results. Of the participants, 83% provided data at the 12-month follow-up and 79% at 36 months. At 12 months, between-group comparison showed a reduction in perceived disability in favor of the exercise group, whereas such an effect for pain emerged only immediately postintervention. Ratings of physical health and self-efficacy beliefs also improved in the exercise group over the long term, though no changes were observed for fear-avoidance beliefs. Conclusion. A graded exercise intervention, emphasizing stabilizing exercises, for patients with recurrent LBP still at work seems more effective in improving disability and health parameters than daily walks do. However, no such positive results emerged for improvement regarding pain over a longer term, or for fear-avoidance beliefs.

Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis

Study Design. Meta-analysis of randomized, controlled trials. Objective. To determine the short-term, intermediate, and long-term effectiveness of MCE, with regard to pain and disability, in patients with chronic and recurrent low-back pain. Summary of Background Data. Previous meta-analyses have shown no difference between the effects of MCE and general exercise in the treatment of low back pain. Several high quality studies on this topic have been published lately, warranting a new meta-analysis. Methods. We searched electronic databases up to October 2011 for randomized controlled trials clearly distinguishing MCE from other treatments. We extracted pain and disability outcomes and converted them to a 0 to 100 scale. We used the RevMan5 (Nordic Cochrane Centre, Copenhagen, Denmark) software to perform pooled analyses to determine the weighted mean differences (WMDs) between MCE and 5 different control interventions. Results. Sixteen studies were included. The pooled results favored MCE compared with general exercise with regard to disability during all time periods (improvement in WMDs ranged from −4.65 to −4.86), and with regard to pain in the short and intermediate term (WMDs were −7.80 and −6.06, respectively). Compared with spinal manual therapy, MCE was superior with regard to disability during all time periods (the WMDs ranged between −5.27 and −6.12), but not with regard to pain. Furthermore, MCE was superior to minimal intervention during all time periods with regard to both pain (the WMDs ranged between −10.18 and −13.32) and disability (the WMDs ranged between −5.62 and −9.00). Conclusion. In patients with chronic and recurrent low back pain, MCE seem to be superior to several other treatments. More studies are, however, needed to investigate what subgroups of patients experiencing LBP respond best to MCE.

Factors predicting clinical outcome 12 and 36 months after an exercise intervention for recurrent low-back pain

Purpose: The aim of this cohort study was to identify early predictive factors for a poor outcome of disability and pain 12- and 36-months after an intervention in patients with recurrent low-back pain, currently at work. Method: Seventy-one patients with recurrent low-back pain, all at work, seeking care in a primary health care setting were included. Predictive indicators including demographic data and health-related variables were derived from questionnaires pre- and post intervention over eight weeks. The dependent outcome variables were perceived disability and present pain at 12- and 36-months. Results: Multivariate regression analyses show that early data on poor self-efficacy for physical activity, greater disability, and higher level of pain-ratings emerged as independent predictors of a poor outcome of disability at 12 and 36 months. Higher ratings of pain and poor self-efficacy appeared again as independent predictors of a poor outcome of pain at the 12-month follow-up. Pain frequency ratings predicted a poor outcome of pain at 36 months. Conclusions: Our results suggest that ratings of poor self-efficacy for physical activity, greater disability, and pain-ratings, are the most consistent independent predictors of long-term poor outcome of disability and pain. This indicates the importance of screening for such factors to optimize the management of low-back pain. However, larger studies in similar patient populations are needed to confirm these results. Implications for Rehabilitation Patients ratings of self-efficacy for physical activities, disability and pain predict long-term poor outcome of perceived disability and pain in subjects with recurrent low-back pain. Prognostic information about self-efficacy for physical activity may be used to tailor intervention to prevent future disablement resulting from further episodes of recurrent low-back pain. It is important to implement knowledge of predictive factors in the clinical work.

Are job strain and sleep disturbances prognostic factors for neck/shoulder/arm pain? : A cohort study of a general population of working age in Sweden

Objective To study whether job strain, that is, psychological job demands and decision latitude, and sleep disturbances among persons with occasional neck/shoulder/arm pain (NSAP) are prognostic factors for having experienced at least one episode of troublesome NSAP, and to determine whether sleep disturbances modify the association between job strain and troublesome NSAP. Design Prospective cohort study. Setting Stockholm, Sweden. Participants A population-based cohort of individuals with occasional NSAP (n=6979) who answered surveys in 2006 and 2010. Outcome measures Report of at least one episode of troublesome NSAP in 2010. Results The ORs for troublesome NSAP at follow-up were in individuals exposed to passive jobs 1.2 (95% CI 0.9 to 1.4); to active jobs 1.3 (95% CI 1.1 to 1.5); to high strain 1.5 (95% CI 1.0 to 2.4); to mild sleep disturbances 1.4 (95% CI 1.3 to 1.6) and to severe sleep disturbances 2.2 (95% CI 1.6 to 3.0). High strain and active jobs were associated with having experienced at least one episode of troublesome NSAP during the previous 6 months in persons with sleep disturbances, but not in individuals without sleep disturbances. Conclusions Our results indicate that high strain, active jobs and sleep disturbances are prognostic factors that should be taken into account when implementing preventive measures to minimise the risk of troublesome NSAP among people of working age. We suggest that sleep disturbances may modify the association between high strain and troublesome NSAP.

The abdominal drawing-in manoeuvre for detecting activity in the deep abdominal muscles: is this clinical tool reliable and valid?

Objective The abdominal drawing-in manoeuvre (ADIM) is a common clinical tool for manually assessing whether a preferential activation of the deep abdominal muscles in patients with low back pain (LBP) is ‘correct’ or not. The validity and reliability of manual assessment of the ADIM are, however, as yet unknown. This study evaluated the concurrent and discriminative validity and reliability of the manually assessed ADIM. Design Single-blinded cross-sectional study. Settings General population in Stockholm County, Sweden. Participants The study sample comprised 38 participants seeking care for LBP, and 15 healthy subjects. Measures The manual ADIM was assessed as correct or not following a standard procedure. Ultrasound imaging (USI) was used as the concurrent reference (gold standard) for the manually assessed ADIM by calculating a ratio of the change in muscle thickness between the resting and the contracted states: the correlation between manual test and USI was calculated. Discriminative validity was analysed by calculating sensitivity and specificity. A sample of 24 participants was analysed with κ coefficients for interobserver reliability between two raters. Results The concurrent validity between the manual ADIM and the ADIM–USI ratios showed poor correlations (r=0.13–0.40). The discriminative validity of the manually assessed ADIM to predict LBP showed a sensitivity/specificity of 0.30/0.73, while the ADIM–USI ratio to predict LBP showed 0.19/0.87. The interobserver reliability for the manually assessed ADIM revealed substantial agreement: K=0.71, CI (95%) 0.41 to 1.00. Conclusions Although the interobserver reliability of the manually assessed ADIM was high, the concurrent and discriminative validity were both low for examining the preferential activity of the deep abdominal muscles. Neither the manually assessed ADIM nor the ultrasound testing discriminated between participants with LBP and healthy subjects regarding preferential activity of the transversus muscle as this ability/inability was also present in healthy subjects.

Intra- and inter-rater reliability of movement and palpation tests in patients with neck pain: A systematic review

ABSTRACT Neck pain is common and often becomes chronic. Various clinical tests of the cervical spine are used to direct and evaluate treatment. This systematic review aimed to identify studies examining the intra- and/or interrater reliability of tests used in clinical examination of patients with neck pain. A database search up to April 2016 was conducted in PubMed, CINAHL, and AMED. The Quality Appraisal of Reliability Studies Checklist (QAREL) was used to assess risk of bias. Eleven studies were included, comprising tests of active and passive movement and pain evaluating participants with ongoing neck pain. One study was assessed with a low risk of bias, three with medium risk, while the rest were assessed with high risk of bias. The results showed differing reliabilities for the included tests ranging from poor to almost perfect. In conclusion, active movement and pain for pain or mobility overall presented acceptable to very good reliability (Kappa >0.40); while passive intervertebral tests had lower Kappa values, suggesting poor reliability. It may be a coincidence that the studies indicating very good reliability tended to be of higher quality (low to moderate risk of bias), while studies finding poor reliability tended to be of lower quality (high risk of bias). Regardless, the current recommendation from this review would suggest the clinical use of tests with acceptable reliability and avoiding the use of tests that have been shown to not be reliable. Finally, it is critical that all future reliability studies are of higher quality with low risk of bias.

Nonsteroidal Anti-inflammatory Drugs for Sciatica : An Updated Cochrane Review

STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To determine the efficacy of Nonsteroidal anti-inflammatory drugs (NSAIDs) on pain reduction, overall improvement, and reported adverse effects in people with sciatica. SUMMARY OF BACKGROUND DATA NSAIDs are one of the most frequently prescribed drugs for sciatica. METHODS We updated a 2008 Cochrane Review through June 2015. Randomized controlled trials that compared NSAIDs to placebo, to other NSAIDs, or to other medication were included. Outcomes included pain using mean difference (MD, 95% confidence intervals 95%CI). For global improvement and adverse effects risk ratios (RR,95% CI) were used. We assessed level of evidence using the GRADE approach. RESULTS Ten trials were included (N = 1651). Nine out of ten trials were assessed at high risk of bias. For pain reduction (Visual Analogue Scale, 0 to 100) NSAIDs were no more effective than placebo (MD -4.56, 95% CI -11.11 to 1.99, quality of evidence: very low). For global improvement NSAIDs were more effective than placebo (RR 1.14 (95%CI 1.03 to 1.27, low quality of evidence). One trial reported the effect of NSAIDs on disability with very low quality evidence that NSAIDs are no more effective than placebo. There was low-quality evidence that the risk for adverse effects is higher for NSAID than placebo (RR 1.40, 95%CI 1.02 to 1.93). CONCLUSION Our findings show very low quality evidence that the efficacy of NSAIDs for pain reduction is comparable to that of placebo, low quality evidence that NSAIDs is better than placebo for global improvement and low quality evidence for higher risk of adverse effects using NSAIDs compared to placebo. The findings must be interpreted with caution, due to small study samples, inconsistent results and a high risk of bias in the included trials.Study Design. Systematic review and meta-analysis. Objective. To determine the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) on pain reduction, overall improvement, and reported adverse effects in people with sciatica. Summary of Background Data. NSAIDs are one of the most frequently prescribed drugs for sciatica. Methods. We updated a 2008 Cochrane Review through June 2015. Randomized controlled trials that compared NSAIDs with placebo, with other NSAIDs, or with other medication were included. Outcomes included pain using mean difference (MD, 95% confidence intervals [95% CI]). For global improvement and adverse effects risk ratios (RR, 95% CI) were used. We assessed level of evidence using the Grades of Recommendation, Assessment, Development and Evaluation approach. Results. Ten trials were included (N = 1651). Nine out of 10 trials were assessed at high risk of bias. For pain reduction (visual analog scale, 0 to 100) NSAIDs were no more effective than placebo (MD −4.56, 95% CI −11.11 to 1.99, quality of evidence: very low). For global improvement NSAIDs were more effective than placebo (RR 1.14 [95% CI 1.03 to 1.27], low quality of evidence). One trial reported the effect of NSAIDs on disability with very low-quality evidence that NSAIDs are no more effective than placebo. There was low-quality evidence that the risk for adverse effects is higher for NSAID than placebo (RR 1.40, 95% CI 1.02 to 1.93). Conclusion. Our findings show very low-quality evidence that the efficacy of NSAIDs for pain reduction is comparable with that of placebo, low-quality evidence that NSAIDs is better than placebo for global improvement and low-quality evidence for higher risk of adverse effects using NSAIDs compared with placebo. The findings must be interpreted with caution, due to small study samples, inconsistent results, and a high risk of bias in the included trials. Level of Evidence: 1