Paul J. Watson

Selective serotonin reuptake inhibitors: meta-analysis of efficacy and acceptability.

OBJECTIVE--To examine the evidence for using selective serotonin reuptake inhibitors instead of tricyclic antidepressants in the first line treatment of depression. DESIGN--Meta-analysis of 63 randomised controlled trials comparing the efficacy and acceptability of selective serotonin reuptake inhibitors with those of tricyclic and related antidepressants. MAIN OUTCOME MEASURES--Improvement in mean scores on Hamilton depression rating scale for 53 randomised controlled trials. Pooled drop out rates from the 58 trials which reported drop out by treatment group. RESULTS--Among the 20 studies reporting standard deviation for the Hamilton score no difference was found in efficacy between serotonin reuptake inhibitors and tricyclic and related antidepressants (standardised mean difference 0.004, 95% confidence interval -0.096 to 0.105). The difference remained insignificant when the remaining 33 studies that used the 17 item and 21 item Hamilton score were included by ascribing weighted standard deviations. The odds ratio for drop out rate in patients receiving serotonin reuptake inhibitors compared with those receiving tricyclic antidepressants was 0.95 (0.86 to 1.07). Similar proportions in both groups cited lack of efficacy as the reason for dropping out but slightly more patients in the tricyclic group cited side effects (18.8% v 15.4% in serotonin reuptake group). CONCLUSIONS--Routine use of selective serotonin reuptake inhibitors as the first line treatment of depressive illness may greatly increase cost with only questionable benefit.

Early Identification and Management of Psychological Risk Factors (“Yellow Flags”) in Patients With Low Back Pain: A Reappraisal

Originally the term “yellow flags” was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability.

Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia.

&NA; The Tampa Scale for Kinesiophobia (TSK) is one of the most frequently employed measures for assessing pain‐related fear in back pain patients. Despite its widespread use, there is relatively little data to support the psychometric properties of the English version of this scale. This study investigated the psychometric properties of the English version of the TSK in a sample of chronic low back pain patients. Item analysis revealed that four items possessed low item total correlations (4, 8, 12, 16) and four items had response trends that deviated from a pattern of normal distribution (4, 9, 12, 14). Consequently, we tested the psychometric properties of a shorter version of the TSK (TSK‐11), having excluded the six psychometrically poor items. The psychometric properties of this measure were compared to those of the original TSK. Both measures demonstrated good internal consistency (TSK: α=0.76; TSK‐11: α=0.79), test–retest reliability (TSK: ICC=0.82, SEM=3.16; TSK‐11: ICC=0.81, SEM=2.54), responsiveness (TSK: SRM=−1.19; TSK‐11: SRM=−1.11), concurrent validity and predictive validity. In respect of specific cut‐off scores, a reduction of at least four points on both measures maximised the likelihood of correctly identifying an important reduction in fear of movement. Overall, the TSK‐11 possessed similar psychometric properties to the original TSK and offered the advantage of brevity. Further research is warranted to investigate the utility of the new instrument and the cut‐off scores in a wider group of chronic pain patients in different clinical settings.

Early management of persistent non-specific low back pain: summary of NICE guidance

Most episodes of acute low back pain resolve spontaneously.1 However, among those in whom low back pain and disability have persisted for over a year, few return to normal activities. Thus the focus for preventing the onset of long term disability caused by non-specific low back pain is on the early management of persistent low back pain (pain present for more than six weeks and less than one year). No consensus exists on how to help health professionals and their patients choose the best treatments for this condition. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the early management of non-specific low back pain.1 The diagnosis of specific causes of low back pain (malignancy, infection, fracture, ankylosing spondylitis, and other inflammatory disorders) is not part of this guideline. NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. The box lists treatments that should not be offered for non-specific low back pain. #### Treatments not recommended for non-specific low back pain ##### Do not offer

Surface electromyography in the identification of chronic low back pain patients: the development of the flexion relaxation ratio

OBJECTIVE: To develop a reliable and repeatable way to monitor changes in the flexion relaxation phenomenon of the lumbar paraspinal muscles during forward flexion by the development of a flexion relaxation ratio and observation of the sEMG activity in standing and during forward flexion in patients with chronic low back pain (CLBP) and healthy controls. DESIGN: Two experiments were conducted, the first to assess the test-retest reliability of the measure in a group of CLBP (n = 11) patients; the second compared the results between a group of normal healthy controls (n = 20) and a group of CLBP patients (n = 70). RESULTS: Repeated measurements over 4 weeks demonstrated between session reliability of between 0.81 and 0.98 for the dynamic activity. The levels of sEMG activity in the fully flexed position was significantly greater in the fully flexed position in the CLBP group than the controls. The flexion relaxation ratio (FRR), a comparison of the maximal sEMG activity during 1 s of forward flexion with activity in full flexion, demonstrated significantly lower values in the CLBP than the control group. The combined discriminant validity for the FRR for all four sites resulted in 93% sensitivity and 75% specificity. CONCLUSION: The FRR clearly discriminated the patients from the healthy controls. These results indicate that dynamic sEMG activity of the paraspinal muscles can be reliably measured and is useful in differentiating CLBP patients from normal controls. RELEVANCE: Analysis of the pattern of different levels of muscle activity during a forward flexion can be used in CLBP where normalization of the sEMG signal to the maximum voluntary contraction may be difficult. The FRR may be used in the assessment of change in the flexion relaxation phenomenon following treatment interventions.

Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: A randomized controlled trial

Study Design. A randomized controlled trial. Objectives. To determine 1) whether, among patients with persistent disabling low back pain (LBP), a group program of exercise and education using a cognitive behavioral therapy (CBT) approach, reduces pain and disability over a subsequent 12-month period; 2) the cost-effectiveness of the intervention; and 3) whether a priori preference for type of treatment influences outcome. Summary of Background Data. There is evidence that both exercise and CBT delivered in specialist settings is effective in improving LBP. There is a lack of evidence on whether such interventions, delivered by trained individuals in primary care, result in improved outcomes. Methods. The study was conducted in nine family medical practices in East Cheshire, UK. Patients 18 to 65 years of age, consulting with LBP, were recruited; those still reporting LBP 3 months after the initial consultation were randomized between the two trial arms. The intervention arm received a program of eight 2-hour group exercise session over 6 weeks comprising active exercise and education delivered by physiotherapists using a CBT approach. Both arms received an educational booklet and audio-cassette. The primary outcome measures were pain (0–100 Visual Analogue Scale) and disability (Roland and Morris Disability Scale; score 0–24). Results. A total of 196 subjects (84%) completed follow-up 12 months after the completion of the intervention program. The intervention showed only a small and nonsignificant effect at reducing pain (−3.6 mm; 95% confidence interval, −8.5, 1.2 mm) and disability (−0.6 score; 95% confidence interval, −1.6, 0.4). The cost of the intervention was low with an incremental cost-effectiveness ratio of £5000 (U.S.

Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients.

8650) per quality adjusted life year. In addition, patients allocated to the intervention that had expressed a preference for it had clinically important reductions in pain and disability. Conclusions. This intervention program produces only modest effects in reducing LBP and disability over a 1-year period. The observation that patient preference for treatment influences outcome warrants further investigation.

The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy.

This study aimed to determine whether self‐efficacy beliefs mediated the relation between pain‐related fear and pain, and between pain‐related fear and disability in CLBP patients who exhibited high pain‐related fear. In a cross‐sectional design, 102 chronic low back pain (CLBP) patients completed measures for pain, disability, self‐efficacy and pain‐related fear (fear of movement and catastrophizing). Multistep regression analyses were performed to determine whether self‐efficacy mediated the relation between pain‐related fear and outcome (pain and/or disability). Self‐efficacy was found to mediate the relation between pain‐related fear and pain intensity, and between pain‐related fear and disability. Therefore, this study suggests that when self‐efficacy is high, elevated pain‐related fear might not lead to greater pain and disability. However, in instances where self‐efficacy is low, elevated pain‐related fear is likely to lead to greater pain and disability. In view of these findings, we conclude that it is imperative to assess both pain‐related fear and self‐efficacy when treating CLBP patients with high pain‐related fear.

Ethnic differences in thermal pain responses : A comparison of South Asian and White British healthy males

The aim of this study was to determine the extent to which a number of distinct cognitive factors were differentially related to the levels of pain and disability reported by 183 chronic low back pain (CLBP) patients presenting for physiotherapy. After adjusting for demographics, the cognitive factors accounted for an additional 30% of the variance in pain intensity, with functional self‐efficacy (β=−0.40; P<0.001) and catastrophizing (β=0.21; P<0.01) both uniquely contributing to the prediction of outcome. The cognitive factors also explained an additional 32% of the variance in disability after adjusting for demographics and pain intensity (total R2=0.61). Higher levels of functional self‐efficacy (β=−0.43; P<0.001) and lower levels of depression (β=0.23; P<0.01) were uniquely related to lower levels of disability. Our findings clearly show that there is a strong association between cognitive factors and the levels of pain and disability reported by CLBP patients presenting for physiotherapy. Functional self‐efficacy emerged as a particularly strong predictor of both pain intensity and disability. In view of our findings it would seem that targeting specific cognitive factors should be an integral facet of physiotherapy‐based treatments for CLBP.

Returning the chronically unemployed with low back pain to employment.

&NA; The expression and report of pain is influenced by social environment and culture. Previous studies have suggested ethnically determined differences in report of pain threshold, intensity and affect. The influence of ethnic differences between White British and South Asians has remained unexplored. Twenty age‐matched, male volunteers in each group underwent evaluation. Cold and warm perception and cold and heat threshold were assessed using an ascending method of limits. Magnitude estimation of pain unpleasantness and pain intensity were investigated with thermal stimuli of 46, 47, 48 and 49 °C. Subjects also completed a pain anxiety questionnaire. Data was analysed using t‐test, Mann–Whitney and repeated measures analysis of variance as appropriate. There were no differences in cold and warm perception between the two groups. There was a statistically significant difference between the two groups for heat pain threshold (P=0.006) and heat pain intensity demonstrated a significant effect for ethnicity (F=13.84, P=0.001). Although no group differences emerged for cold pain threshold and heat unpleasantness, South Asians demonstrated lower cold pain threshold and reported more unpleasantness at all temperatures but this was not statistically significant. Our study shows that ethnicity plays an important role in heat pain threshold and pain report, South Asian males demonstrated lower pain thresholds and higher pain report when compared with matched White British males. There were no differences in pain anxiety between the two groups and no correlations were identified between pain and pain anxiety Haemodynamic measures and anthropometry did not explain group differences.