Lucíola da Cunha Menezes Costa

Prognosis for patients with chronic low back pain: inception cohort study

Objectives To describe the course of chronic low back pain in an inception cohort and to identify prognostic markers at the onset of chronicity. Design Inception cohort study with one year follow-up. Setting Primary care clinics in Sydney, Australia. Participants The study sample was a subcohort of an inception cohort of 973 consecutive patients presenting to primary care with acute low back pain (<2 weeks’ duration). 406 participants whose pain persisted for three months formed the inception cohort of patients with chronic low back pain. Main outcome measures Outcomes and putative predictors measured at initial presentation, onset of chronicity (study entry), and follow-up at nine and 12 months. Recovery was determined from measures of pain intensity, disability, and work status. The association between potential prognostic factors and time to recovery was modelled with Cox regression. Results Completeness of follow-up was 97% of total person time for all outcomes. The cumulative probability of being pain-free was 35% at nine months and 42% at 12 months and for complete recovery was 35% at nine months and 41% at 12 months. Of the 259 participants who had not recovered from pain related disability at entry to the chronic study, 47% had recovered by 12 months. Previous sick leave due to low back pain, high disability levels or high pain intensity at onset of chronicity, low levels of education, greater perceived risk of persistent pain, and being born outside Australia were associated with delayed recovery. Conclusion More than one third of patients with recent onset, non-radicular chronic low back pain recover within 12 months. The prognosis is less favourable for those who have taken previous sick leave for low back pain, have high disability levels or high pain intensity at onset of chronic low back pain, have lower education, perceive themselves as having a high risk of persistent pain, and were born outside Australia.

The prognosis of acute and persistent low-back pain: a meta-analysis

Background: Although low-back pain is a highly prevalent condition, its clinical course remains uncertain. Our main objective was to systematically review the literature on the clinical course of pain and disability in patients with acute and persistent low-back pain. Our secondary objective was to investigate whether pain and disability have similar courses. Methods: We performed a meta-analysis of inception cohort studies. We identified eligible studies by searching MEDLINE, Embase and CINAHL. We included prospective studies that enrolled an episode-inception cohort of patients with acute or persistent low-back pain and that measured pain, disability or recovery. Two independent reviewers extracted data and assessed methodologic quality. We used mixed models to determine pooled estimates of pain and disability over time. Results: Data from 33 discrete cohorts (11 166 participants) were included in the review. The variance-weighted mean pain score (out of a maximum score of 100) was 52 (95% CI 48–57) at baseline, 23 (95% CI 21–25) at 6 weeks, 12 (95% CI 9–15) at 26 weeks and 6 (95% CI 3–10) at 52 weeks after the onset of pain for cohorts with acute pain. Among cohorts with persistent pain, the variance-weighted mean pain score (out of 100) was 51 (95% CI 44–59) at baseline, 33 (95% CI 29–38) at 6 weeks, 26 (95% CI 20–33) at 26 weeks and 23 (95% CI 16–30) at 52 weeks after the onset of pain. The course of disability outcomes was similar to the time course of pain outcomes in the acute pain cohorts, but the pain outcomes were slightly worse than disability outcomes in the persistent pain cohorts. Interpretation: Patients who presented with acute or persistent low-back pain improved markedly in the first six weeks. After that time improvement slowed. Low to moderate levels of pain and disability were still present at one year, especially in the cohorts with persistent pain.

Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain

Pain self-efficacy and fear of movement have been proposed to explain how pain can lead to disability for patients with chronic low back pain. However the extent to which pain self-efficacy and fear of movement mediate the relationship between pain and disability over time has not been investigated. This study aimed to investigate whether pain self-efficacy and/or fear of movement mediate the relationship between pain intensity and disability in patients with recent onset chronic low back pain. In a two-wave longitudinal design, 184 chronic low back pain patients completed measures for pain intensity, disability, pain self-efficacy and fear of movement at baseline and 12months after the onset of chronic low back pain. Regression analyses were used to test the mediational hypothesis. We found that, when measured at the same time, both pain self-efficacy and fear of movement beliefs partially mediated the effects of pain intensity on disability at the onset of chronic low back pain. However, in the longitudinal analyses, only improvements in self-efficacy beliefs partially mediated the relationship between changes in pain and changes in disability over a 12months period. We found no support for the theory that fear of movement beliefs mediate this relationship. Therefore, we concluded that pain self-efficacy may be a more important variable than fear of movement beliefs in terms of understanding the relationship between pain and disability.Pain self‐efficacy and fear of movement have been proposed to explain how pain can lead to disability for patients with chronic low back pain. However the extent to which pain self‐efficacy and fear of movement mediate the relationship between pain and disability over time has not been investigated. This study aimed to investigate whether pain self‐efficacy and/or fear of movement mediate the relationship between pain intensity and disability in patients with recent onset chronic low back pain. In a two‐wave longitudinal design, 184 chronic low back pain patients completed measures for pain intensity, disability, pain self‐efficacy and fear of movement at baseline and 12 months after the onset of chronic low back pain. Regression analyses were used to test the mediational hypothesis. We found that, when measured at the same time, both pain self‐efficacy and fear of movement beliefs partially mediated the effects of pain intensity on disability at the onset of chronic low back pain. However, in the longitudinal analyses, only improvements in self‐efficacy beliefs partially mediated the relationship between changes in pain and changes in disability over a 12 months period. We found no support for the theory that fear of movement beliefs mediate this relationship. Therefore, we concluded that pain self‐efficacy may be a more important variable than fear of movement beliefs in terms of understanding the relationship between pain and disability.

Current evidence does not support the use of Kinesio Taping in clinical practice: a systematic review

QUESTIONS Is Kinesio Taping more effective than a sham taping/placebo, no treatment or other interventions in people with musculoskeletal conditions? Is the addition of Kinesio Taping to other interventions more effective than other interventions alone in people with musculoskeletal conditions? DESIGN Systematic review of randomised trials. PARTICIPANTS People with musculoskeletal conditions. INTERVENTION Kinesio Taping was compared with sham taping/placebo, no treatment, exercises, manual therapy and conventional physiotherapy. OUTCOME MEASURES Pain intensity, disability, quality of life, return to work, and global impression of recovery. RESULTS Twelve randomised trials involving 495 participants were included in the review. The effectiveness of the Kinesio Taping was tested in participants with: shoulder pain in two trials; knee pain in three trials; chronic low back pain in two trials; neck pain in three trials; plantar fasciitis in one trial; and multiple musculoskeletal conditions in one trial. The methodological quality of eligible trials was moderate, with a mean of 6.1 points on the 10-point PEDro Scale score. Overall, Kinesio Taping was no better than sham taping/placebo and active comparison groups. In all comparisons where Kinesio Taping was better than an active or a sham control group, the effect sizes were small and probably not clinically significant or the trials were of low quality. CONCLUSION This review provides the most updated evidence on the effectiveness of the Kinesio Taping for musculoskeletal conditions. The current evidence does not support the use of this intervention in these clinical populations. PROSPERO registration: CRD42012003436.

Primary Care Research Priorities in Low Back Pain An Update

Study Design. Survey report. Objective. To reassess an existing list of research priorities in primary care low back pain (LBP) and to develop a new research agenda. Summary of Background Data. Primary care LBP researchers developed an agenda of research priorities in 1997 at an international conference. In 2009, a survey was conducted to re-evaluate the 1997 research priorities and to develop a new research agenda. Methods. Two-phase, Internet-based survey of participants in one of the LBP primary care research fora. The first phase collected information on importance, feasibility, and progress for the 1997 priorities; during this phase, the respondents were also asked to list the 5 most important current primary care–relevant LBP research questions. The second phase ranked these current research priorities. Results. A total of 179 persons responded to the first phase, representing 30% of those surveyed. Rankings of the 1997 priorities were somewhat similar compared with 2009, although research on beliefs and expectations and improving the quality of LBP research became more important, and research on guidelines and psychosocial interventions became less important. Organizing more effective primary care for LBP, implementing best practices, and translating research to practice were ranked higher compared with 1997. Most priorities were also ranked as relatively feasible. The new agenda was similar, and included subgroup-based treatment and studies on causes and mechanisms of LBP as new top priorities. Conclusion. Changes in research priorities seem to reflect recent advances, new opportunities, and limitations in our ability to improve care.

Systematic review of cross-cultural adaptations of McGill Pain Questionnaire reveals a paucity of clinimetric testing

OBJECTIVES The objectives of this study were to identify the available cross-cultural adaptations of the McGill Pain Questionnaire (MPQ), to describe the clinimetric testing that has occurred for each adaptation and to evaluate both the quality of the adaptation procedures and the clinimetric testing for each version. STUDY DESIGN AND SETTING This study is a systematic review. Searches of the MEDLINE, EMBASE, and CINAHL databases were used to identify relevant studies. Data on the quality of the adaptation procedures and clinimetric testing were extracted using current guidelines. RESULTS Forty-four different versions of the MPQ were identified representing 26 different languages/cultures. Regardless of the method of cross-cultural adaptation, clinimetric testing of the adapted questionnaires was generally poorly performed and for 18 versions no clinimetric testing has been undertaken. CONCLUSIONS Although the MPQ has been adapted into a large number of languages, because of inadequate testing most of the adaptations have unknown clinimetric properties. This situation means that users should be cautious when interpreting scores from adapted questionnaires.

What low back pain is and why we need to pay attention

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Kinesio Taping to generate skin convolutions is not better than sham taping for people with chronic non-specific low back pain: a randomised trial

QUESTION For people with chronic low back pain, does Kinesio Taping, applied according to the treatment manual to create skin convolutions, reduce pain and disability more than a simple application without convolutions? DESIGN Randomised trial with concealed allocation, intention-to-treat analysis and blinded assessment of some outcomes. PARTICIPANTS 148 participants with chronic non-specific low back pain. INTERVENTION Experimental group participants received eight sessions (over four weeks) of Kinesio Taping applied according to the Kinesio Taping Method treatment manual (ie, 10 to 15% tension applied in flexion to create skin convolutions in neutral). Control group participants received eight sessions (over four weeks) of Kinesio Taping with no tension, creating no convolutions. OUTCOME MEASURES The primary outcome measures were pain intensity and disability after the four-week intervention. Secondary outcomes were pain intensity and disability 12 weeks after randomisation, and global perceived effect at both four and 12 weeks after randomisation. RESULTS Applying Kinesio Tape to create convolutions in the skin did not significantly change its effect on pain (MD-0.4 points, 95% CI-1.3 to 0.4) or disability (MD-0.3 points, 95% CI-1.9 to 1.3) at four weeks. There was a small difference in favour of the experimental group for the secondary outcome of global perceived effect (MD 1.4 points, 95% CI 0.3 to 2.5) at four weeks. No significant between-group differences were observed for the other secondary outcomes. CONCLUSION Kinesio Taping applied with stretch to generate convolutions in the skin was no more effective than simple application of the tape without tension for the outcomes measured. These results challenge the proposed mechanism of action of this therapy. TRIAL REGISTRATION Brazilian Registry of Clinical Trials, RBR-7ggfkv.

Prevention and treatment of low back pain: evidence, challenges, and promising directions

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

Does fear of movement mediate the relationship between pain intensity and disability in patients following whiplash injury? A prospective longitudinal study

Summary In a cohort of patients with whiplash injuries, fear avoidance partially mediated the relationship between pain soon after injury and disability 3 months later. ABSTRACT The aim of this study was to test the capacity of the Fear Avoidance Model to explain the relationship between pain and disability in patients with whiplash‐associated disorders. Using the method of Baron and Kenny [1], we assessed the mediating effect of fear of movement on the cross‐sectional and longitudinal relationships between pain and disability. Two hundred and five subjects with neck pain due to a motor vehicle accident provided pain intensity (0 to 10 numerical rating scale), fear of movement (Tampa Scale of Kinesiophobia and Pictorial Fear of Activity Scale) and disability (Neck Disability Index) scores within 4 weeks of their accident, after 3 months, and after 6 months. The analyses were consistent with the Fear Avoidance Model mediating approximately 20% to 40% of the relationship between pain and disability. Contrary to our initial hypothesis, the proportion of the total effect of pain on disability that was mediated by fear of movement did not substantially change as increasing time elapsed after the accident. The proportion mediated was slightly higher when fear of movement was measured by Tampa Scale of Kinesiophobia as compared with Pictorial Fear of Activity Scale. The findings of this study suggest that the Fear Avoidance Model plays a role in explaining a moderate proportion of the relationship between pain and disability after whiplash injury.