Lois Tonkin

Effect of Motor Control Exercises Versus Graded Activity in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial

Background Motor control exercises to improve control and coordination of trunk muscles and graded activity under the principles of cognitive-behavioral therapy are 2 commonly used exercise therapies, yet there is little evidence to support the use of one intervention over the other. Objective The objective of this study was to compare the effectiveness of motor control exercises and graded activity for patients with chronic nonspecific low back pain. Design This study was a prospectively registered randomized controlled trial with outcome assessment and statistical analyses conducted blind to group. Setting The study was conducted in primary care settings. Patients The participants were 172 patients with chronic (>12 weeks) nonspecific low back pain. Interventions Patients were randomly assigned to receive either motor control exercises or graded activity. There was no attempt to subclassify patients to match them to a treatment. Patients in both groups received 14 sessions of individualized, supervised exercise therapy. Measurements Primary outcomes were average pain over the previous week (numeric rating scale) and function (Patient-Specific Functional Scale); secondary outcomes were disability (24-item Roland-Morris Disability Questionnaire), global impression of change (Global Perceived Effect Scale), and quality of life (36-Item Short-Form Health Survey questionnaire [SF-36]). Outcome measures were collected at baseline and at 2, 6, and 12 months after intervention. Results A linear mixed models analysis showed that there were no significant differences between treatment groups at any of the time points for any of the outcomes studied. For example, the effect for pain at 2 months was 0.0 (−0.7 to 0.8). Limitations Clinicians could not be blinded to the interventions. Conclusion The results of this study suggest that motor control exercises and graded activity have similar effects for patients with chronic nonspecific low back pain.

Stretch Exercises Increase Tolerance to Stretch in Patients With Chronic Musculoskeletal Pain: A Randomized Controlled Trial

Background: Stretch is commonly prescribed as part of physical rehabilitation in pain management programs, yet little is known about its effectiveness. Objective: A randomized controlled trial was conducted to investigate the effects of a 3-week stretch program on muscle extensibility and stretch tolerance in patients with chronic musculoskeletal pain. Design: A within-subject design was used, with one leg of each participant randomly allocated to an experimental (stretch) condition and the other leg randomly allocated to a control (no-stretch) condition. Patients and Setting: Thirty adults with pain of musculoskeletal origin persisting for at least 3 months were recruited from patients enrolled in a multidisciplinary pain management program at a hospital in Sydney, Australia. Intervention: The hamstring muscles of the experimental leg were stretched daily for 1 minute over 3 weeks; the control leg was not stretched. This intervention was embedded within a pain management program and supervised by physical therapists. Measurements: Primary outcomes were muscle extensibility and stretch tolerance, which were reflected by passive hip flexion angles measured with standardized and nonstandardized torques, respectively. Initial measurements were taken before the first stretch on day 1, and final measurements were taken 1 to 2 days after the last stretch. A blinded assessor was used for testing. Results: Stretch did not increase muscle extensibility (mean between-group difference in hip flexion was 1°, 95% confidence interval=−2° to 4°), but it did improve stretch tolerance (mean between-group difference in hip flexion was 8°, 95% confidence interval=5° to 10°). Conclusion: Three weeks of stretch increases tolerance to the discomfort associated with stretch but does not change muscle extensibility in patients with chronic musculoskeletal pain.

Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain?

There is generally good evidence that pain management interventions that include self‐management strategies can substantially reduce disability and improve psychological well‐being in patients with chronic pain. Reductions in unhelpful responses, especially catastrophising and fear‐avoidance beliefs, have been established as key contributors to these gains. In contrast, there is surprisingly little evidence that adherence to self‐management strategies contributes to achieving these outcomes. Difficulties in defining and measuring the use of pain self‐management strategies have been obstacles for this research. Using a pragmatic way of assessing the practice of specific strategies this study investigated their ability to account for changes in pain, disability and depressive symptoms after a 3‐week cognitive‐behavioural pain management program. The post‐treatment outcomes on these dimensions were found to be statistically and, for many, clinically significant. Consistent with previous research, reductions in catastrophising and fear‐avoidance beliefs, and increased pain self‐efficacy beliefs, were also associated with these gains. But the key new finding was that there was a clear gradient between adherence to specific self‐management strategies and reductions in pain, disability and depressive symptoms. Furthermore, adherence to the self‐management strategies was predictive of better outcomes even after controlling for the moderating effects of initial catastrophising, fear‐avoidance and pain self‐efficacy beliefs.

Motor control or graded activity exercises for chronic low back pain? A randomised controlled trial

BackgroundChronic low back pain remains a major health problem in Australia and around the world. Unfortunately the majority of treatments for this condition produce small effects because not all patients respond to each treatment. It appears that only 25–50% of patients respond to exercise. The two most popular types of exercise for low back pain are graded activity and motor control exercises. At present however, there are no guidelines to help clinicians select the best treatment for a patient. As a result, time and money are wasted on treatments which ultimately fail to help the patient.MethodsThis paper describes the protocol of a randomised clinical trial comparing the effects of motor control exercises with a graded activity program in the treatment of chronic non specific low back pain. Further analysis will identify clinical features that may predict a patients response to each treatment. One hundred and seventy two participants will be randomly allocated to receive either a program of motor control exercises or graded activity. Measures of outcome will be obtained at 2, 6 and 12 months after randomisation. The primary outcomes are: pain (average pain intensity over the last week) and function (patient-specific functional scale) at 2 and 6 months. Potential treatment effect modifiers will be measured at baseline.DiscussionThis trial will not only evaluate which exercise approach is more effective in general for patients will chronic low back pain, but will also determine which exercise approach is best for an individual patient.Trial registration numberACTRN12607000432415

Cognitive exposure versus avoidance in patients with chronic pain: Adherence matters

Behavioural exposure methods can reduce pain‐avoidance behaviours, but outcomes vary. One possible explanation is that patients employ cognitive (experiential) avoidance during behavioural exposure. If so, reducing cognitive avoidance during behavioural exposure should help. One option is interoceptive exposure (IE), which involves sustained exposure (via attention) to pain sensations. In order to test if IE could improve outcomes from behavioural exposure, this study with mixed chronic pain patients compared outcomes from a cognitive behavioural therapy (CBT) pain management programme incorporating either IE or distraction from pain.

Does a Combination of Intensive Cognitive-Behavioral Pain Management and a Spinal Implantable Device Confer any Advantage? A Preliminary Examination

Abstract:  Research suggests that a combination of a somatic and a psychosocial intervention for chronic noncancer pain should be associated with a better outcome than either alone. This study presents data on a series of 31 patients who underwent sequential treatment with an implantable device targeting pain relief and a cognitive‐behavioral pain management program that targeted improved function. A combination of treatments was used as there was a suboptimal response to the initial treatment. There were improvements in a range of outcomes at a long‐term follow‐up. Significant improvements were found in disability, affective distress, self‐efficacy, and catastrophizing, but not in average pain severity. Further analyses failed to demonstrate an order effect. These results support the view that combined somatic and psychosocial interventions can achieve better outcomes than either alone in selected chronic pain patients. This approach requires that psychological assessment is essential before the use of an implantable device. This may not only improve patient selection, but also identify psychosocial factors that may be modified to enhance the effectiveness of invasive interventions. In addition, consideration for an implantable device following a suboptimal response to treatment in a cognitive‐behavioral pain management program should include a re‐evaluation of the patients’ beliefs and use of self‐management (coping) strategies before deciding on further treatment options.

Self-management of chronic pain in Malaysian patients: effectiveness trial with 1-year follow-up

ABSTRACTSelf-management of chronic illnesses has been widely recognised as an important goal on quality of life, health service utilisation and cost grounds. This study describes the first published account on the application of this approach to people suffering from chronic pain conditions in a Southeast Asian country, Malaysia. A heterogeneous sample of chronic pain patients in Malaysia attended a 2-week cognitive–behavioural pain management programme (PMP) aimed at improving daily functional activities and general psychological well-being. Complete datasets from 70 patients out of 102 patients who attended 11 programmes conducted from 2002 to 2007, as well as the 1-month and 1-year follow-up sessions at the hospital clinic, are reported. The pre- to post-treatment results on self-report measures indicate that significant gains were achieved on the dimensions of pain, disability and psychological well-being. These gains were maintained at both 1-month and 1-year follow-ups. The results mirror those reported from similar interventions in Europe and North America and indicate the concept of self-management of a chronic illness is acceptable and meaningful to Asian patients. Importantly, the achieved outcomes were independent of gender and ethnic group status.