Judith M. Sieben

A longitudinal study on the predictive validity of the fear-avoidance model in low back pain

&NA; Recently, fear–avoidance models have been quite influential in understanding the transition from acute to chronic low back pain (LBP). Not only has pain‐related fear been found to be associated with disability and increased pain severity, but also treatment focused at reducing pain‐related fear has shown to successfully reduce disability levels. In spite of these developments, there is still a lack in well‐designed prospective studies examining the role of pain‐related fear in acute back pain. The aim of the current study was to prospectively test the assumption that pain‐related fear in acute stages successfully predicts future disability. Subjects were primary care acute LBP patients consulting because of a new episode of LBP (≤3 weeks). They completed questionnaires on background variables, fear–avoidance model variables and LBP outcome (Graded Chronic Pain Scale, GCPS) at baseline, 3, 6, and 12 months follow‐up and at the end of the study. Two‐hundred and twenty‐two acute LBP patients were included, of whom 174 provided full follow‐up information (78.4%). A backward ordinal regression analysis showed previous LBP history and pain intensity to be the most important predictors of end of study GCPS. Of the fear–avoidance model variables, only negative affect added to this model. Our results do not really support the longitudinal validity of the fear–avoidance model, but they do feed the discussion on the role of pain‐related fear in early stages of LBP.

Pain-related fear in acute low back pain: the first two weeks of a new episode.

The overall aim of this study was to explore the natural course of pain‐related fear during the early stage of a new low back pain episode, using a prospective case series design. Specific research questions addressed the existence of typical patterns in individual time series of pain‐related fear and sequential relationships between the occurrence of pain‐related fear, pain and pain catastrophizing. Forty‐four general practice patients who consulted their physician with a new episode of non‐specific low back pain were recruited. They completed diaries on pain‐related fear, pain and pain catastrophizing for 14 days following the consultation. Follow‐up questionnaires on disability were completed at 3 months and 12 months. Time series analyses produced subgroups of patients with descending, stable and rising levels of pain‐related fear over the 2‐week period. These groups differed on baseline characteristics and outcome at follow‐up. A time‐shift between the occurrence of pain‐events and pain‐related fear or pain catastrophizing could not be demonstrated.

Decline in physical activity, disability and pain-related fear in sub-acute low back pain

Aim of investigation: To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub‐acute back pain.

Pain-related fear at the start of a new low back pain episode.

Previous research supports the fear‐avoidance model in explaining chronic low back pain (LBP) disability. The aims of the present study were to determine: (1) whether fear‐avoidance model variables are associated already during acute stages of LBP and (2) whether (increases in) pain‐related fear are associated with other patient characteristics routinely assessed by the General Practitioner (GP).

Hip abductor control in walking following stroke — the immediate effect of canes, taping and TheraTogs on gait

Objective: To confirm previous findings that hip abductor activity measured by electromyography (EMG) on the side contralateral to cane use is reduced during walking in stroke patients. To assess whether an orthosis (TheraTogs) or hip abductor taping increase hemiplegic hip abductor activity compared with activity during cane walking or while walking without aids. To investigate the effect of each condition on temporo-spatial gait parameters. Design: Randomized, within-participant experimental study. Setting: Gait laboratory. Subjects: Thirteen patients following first unilateral stroke. Intervention: Data collection over six gait cycles as subjects walked at self-selected speed during: baseline (without aids) and in randomized order with (1) hip abductor taping, (2) TheraTogs, (3) cane in non-hemiplegic hand. Main measures: Peak EMG of gluteus medius and tensor fascia lata and temporo-spatial gait parameters. Results: Cane use reduced EMG activity in gluteus medius from baseline by 21.86%. TheraTogs increased it by 16.47% (change cane use—TheraTogs P=0.001, effect size = -0.5) and tape by 5.8% (change cane use—tape P=0.001, effect size = -0.46). In tensor fascia lata cane use reduced EMG activity from baseline by 19.14%. TheraTogs also reduced EMG activity from baseline by 1.10% (change cane use—TheraTogs P=0.009, effect size -0.37) and tape by 3% (not significant). Gait speed (m/s) at: baseline 0.44, cane use 0.45, tape 0.48, TheraTogs 0.49. Conclusion: Hip abductor taping and TheraTogs increase hemiplegic hip abductor activity and gait speed during walking compared with baseline and cane use.

A tailored exercise program versus general exercise for a subgroup of patients with low back pain and movement control impairment: A randomised controlled trial with one-year follow-up

BACKGROUND Exercise is an effective treatment for patients with sub-acute and chronic non-specific low back pain (NSLBP). Previous studies have shown that a subgroup of patients with NSLBP and movement control impairment (MCI) can be diagnosed with substantial reliability. However, which type of exercises are most beneficial to this subgroup is still unknown. OBJECTIVES The effectiveness of a specific exercise treatment to improve movement control was tested in this study. METHODS Using a multicentre randomised controlled trial (RCT), we compared exercises that targeted MCI (MC) with a general exercise (GE) treatment. After randomisation, patients in both groups n(MC = 52; GE = 54) were treated in eight private physiotherapy practices and five hospital outpatient physiotherapy centres. Follow-up measurements were taken at post-treatment, six months and 12 months. The primary outcome measurement was the Patient Specific Function Scale (PSFS). RESULTS PSFS showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year. CONCLUSION This study found no additional benefit of specific exercises targeting MCI.

A new episode of low back pain: Who relies on bed rest?

Bed rest has been shown to be an ineffective treatment for non‐specific low back pain (LBP). Despite this, during a new episode of pain some patients still rely on bed rest. Which patients choose bed rest is however unknown. The objectives of the present study were, firstly, to assess characteristics of patients choosing bed rest in (sub)acute pain and secondly to study whether prolonged bed rest in the (sub)acute phase of pain will result in long term disability. A prospective longitudinal cohort study included 282 patients with non‐specific LBP for less than 7 weeks. Main outcome measures were duration of bed rest (in three categories) and disability. Results showed that 33% of patients with (sub)acute LBP had bed rest, but only 8% stayed in bed for more than four days. An ordinal regression analysis revealed that behavioural factors (catastrophizing (OR=1.05 per bed rest category p<0.01)) and fear of injury (OR=1.05 per category p<0.01) rather than specific pain related factors (pain history (OR=0.61 per category p=0.16) and pain intensity (OR=1.00 per category p=0.63)) were associated with bed rest. Patients with prolonged bed rest in an early phase of pain were still more disabled after one year (p<0.01). Based on these results we conclude that prolonged bed rest in the early phase of pain is associated with a higher long term disability level. In preventing low back disability, GP screening for catastrophizing and fear of injury in LBP patients who had prolonged bed rest merits consideration.

Movement control exercise versus general exercise to reduce disability in patients with low back pain and movement control impairment : a randomised controlled trial

BackgroundNon-specific low back pain (NSLBP) in subacute and chronic stages can be treated effectively with exercise therapy. Research guidelines recommend evaluating different treatments in defined subgroups of patients with NSLBP. A subgroup of patients with movement control impairment (MCI) improved significantly on patient specific function and disability in a previous case series after movement control exercises.Methods/DesignIn a randomised controlled trial (RCT) we will compare the effectiveness of movement control and general exercise in patients with MCI. 106 participants aged 18 - 75 will be recruited in 5 outpatient hospital departments and 7 private practices.Patients randomly assigned to the movement control exercise group will be instructed to perform exercises according to their MCI. The general exercise group will follow an exercise protocol aimed at improving endurance and flexibility. Patients in both groups will receive 9 - 18 treatments and will be instructed to do additional exercises at home.The primary outcome is the level of disability assessed using the patient specific functional scale (PSFS) which links the perceived pain to functional situations and is measured before treatment and at 6 and 12 months follow-up. Secondary outcomes concern low back pain related disability (Roland Morris questionnaire, RMQ), graded chronic pain scale (GCPS), range of motion and tactile acuity.DiscussionTo our knowledge this study will be the first to compare two exercise programs for a specific subgroup of patients with NSLBP and MCI. Results of this study will provide insight into the effectiveness of movement control exercise and contribute to our understanding of the mechanisms behind MCI and its relation to NSLBP.Trial registrationCurrent Controlled Trials ISRCTN80064281

Influence of Fear-Avoidance Beliefs on Disability in Patients With Subacromial Shoulder Pain in Primary Care: A Secondary Analysis

Background Little information exists about the role of fear-avoidance beliefs and catastrophizing in subacromial pain syndrome. Objective The purpose of this study was to investigate the associations among pain, catastrophizing, fear, and disability and the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up. Design A cross-sectional and longitudinal analysis was conducted. Methods Baseline demographic and clinical data, including fear-avoidance beliefs and catastrophizing, of 90 patients were assessed for this analysis. Disability was measured with the Shoulder Pain and Disability Index at baseline and at 3-month follow-up. First, bivariate and partial correlations were calculated among pain, fear-avoidance beliefs, catastrophizing, and disability, based on the fear-avoidance model. Second, the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up was examined with hierarchical regression analyses. Results Correlations between clinical variables and disability were largely in line with the fear-avoidance model. Regression analyses identified a significant contribution of fear-avoidance beliefs to baseline disability but not to disability at 3 months. Limitations Patients with subacromial pain syndrome were studied; therefore, the results should be transferred with caution to other diagnoses. A modified version of the Fear-Avoidance Beliefs Questionnaire was used, which was not validated for this patient group. Conclusions Fear-avoidance beliefs contribute significantly to baseline disability but not to disability change scores after 3-month follow-up. Duration of complaints and baseline disability were the main factors influencing disability change scores. Although the results help to improve understanding of the role of fear-avoidance beliefs, further studies are needed to fully understand the influence of psychological and clinical factors on the development of disability in patients with subacromial shoulder pain.

General practitioners' treatment orientations towards low back pain: influence on treatment behaviour and patient outcome.

Background: In low back pain (LBP) treatment and research attention has shifted from a biomedical towards a biopsychosocial approach. Patients’ LBP beliefs and attitudes were found to predict long‐term outcome, and recently it has been suggested that the health care providers’ ideas about LBP are also important predictors of treatment behaviour and outcome.