Petra Saur

Effectiveness of a multimodal treatment program for chronic low-back pain

&NA; In recent years, multidisciplinary pain programs were seen to successfully treat patients by basing treatment on a combination of physical exercise and psychological interventions. However, in spite of their effectiveness, it still remains to be clarified exactly which features of these programs were responsible for patient improvement. Cognitive‐behavioral models posit that improvement is due, in part, to changes in patient coping strategies. Nonetheless, as reflected by the conflicting opinions present in the literature, it is questionable whether a so‐called ‘cognitive shift’ is an accurate indicator for return to work of disabled patients. Ninety patients with chronic low back pain took part in a multidisciplinary treatment program. Therapeutic environment reinforces wellness behavior and enhances the patients’ sense of control over their pain and resulting disability. The main therapeutic target point was to facilitate return to work. Ways of coping were measured by a well studied coping inventory in the German language (FEKB). Factor analysis revealed three factors: ‘catastrophizing’, ‘search for information’ and ‘cognitive control’. In addition, assessment included measurements of pain intensity, depression, disability, flexibility of the lumbar spine, and different performance parameters. All of them were measured prior to and at the end of treatment, and following intervals of 6 and 12 months after discharge from program. Measurements showed significant changes over time, but more importantly, nearly all results were seen to stabilize at the 6‐ and 12‐month evaluation following treatment. The coping strategies demonstrated little or poor change. In addition, coping measures and change in coping behavior showed poor prognostic relevance. But other psycho‐social parameters like self‐evaluation of potential return‐to‐work, application for pension, the length of pre‐absence from work, and a decrease in subjective disability following treatment were effective indicators for ‘back‐to‐work’. Other objective parameters, such as medical history, physical impairment and general physical variables were seen to have little predictive value in determining a return to work. The results suggest that the primary target point for further investigation is the analysis of the patients’ beliefs about their pain. Our results indicate that future research must be attentive to the complex interactions between environmental factors and the coping demands posed by the specific nature of pain problems.

Lumbar Range of Motion: Reliability and Validity of the Inclinometer Technique in the Clinical Measurement of Trunk Flexibility

Study Design. This study examines the reliability and validity of measuring lumbar range of motion with an inclinometer. Objectives. To find out whether a manual determination of the reference points for measuring lumbar range of motion is as reliable as radiologic determination for positioning the inclinometers, lumbar range of motion was determined in degrees by evaluating radiographs and by using the inclinometer technique of Loebl. Summary of Background Data. Reliability and validity of the inclinometer technique as a clinical measurement of trunk flexibility were investigated. Fifty‐four patients participated in the study. Methods. Lumbar range of motion measurements were taken with and without radiologic control of the T12 and S1 vertebrae as reference points for positioning of the inclinometers. An interrater correlation was done of the inclinometer techniques of a physician and a physiotherapist. Functional radiographs were investigated in a standing position. Lumbar range of motion measurements based on radiographs and those taken using the inclinometer alone were correlated to validate the inclinometer technique. Results. Lumbar range of motion measurements taken with and without radiologic determination showed a very close correlation (r = 0.93; P < 0.001). Flexion alone also demonstrated a close correlation (r = 0.95; P < 0.001), whereas extension showed a somewhat smaller correlation (r = 0.82; P < 0.001). Total lumbar range of motion (r = 0.94; P < 0.001) and flexion (r = 0.88; P < 0.001) were closely related, as indicated by the interrater correlation, whereas extension (r = 0.42; P < 0.05) showed a lesser correlation. Correlation of the measurements taken radiographically and by inclinometer demonstrated an almost linear correlation for measurements of the total lumbar range of motion (r = 0.97; P < 0.001) and flexion (r = 0.98; P < 0.001), whereas extension (r = 0.75; P < 0.001) did not correlate as well. Conclusions. The noninvasive inclinometer technique proved to be highly reliable and valid, but the measurement technique for extension needs further refinement.

Das Göttinger Rücken Intensiv Programm (GRIP)—ein multimodales behandlungsprogramm für Patienten mit chronischen Rückenschmerzen, Teil 3. Psychosoziale Aspekte

ZusammenfassungProblem Die Relevanz psychologischer Variablen in der Behandlung chronischer Rückenschmerzpatienten konnte vielfach demonstriert werden. Dennoch ist bisher noch nicht eindeutig nachgewiesen, inwieweit subjektives Erleben der Patienten und objektiv meßbare Kriterien im Zusammenhang stehen und welche Bedeutung ihnen im Rahmen einer multimodalen Behandlung zukommt.Methode 90 vorwiegend arbeitsunfähige Patienten mit Rückenschmerzen wurden jeweils in Gruppen à 8–10 Patienten jeweils 8 Wochen lang ambulant in einem standardisierten Vorgehen verhaltensund trainingstherapeutisch behandelt. Neben Aerobic, funktionellem Kraft-training, Herz-Kreislauf-Ausdauer- und Arbeitstraining wurde über 5 Wochen täglich eine 2 stündige kognitiv-behaviorale (Gruppen-)Verhaltenstherapie durchgeführt. Die Ziele des psychotherapeutischen Vorgehens waren eine Veränderung problematischer Verhaltens-dispositionen (Inaktivität, Rückzug), maladaptiver Kognitionen (Somatisierung, Katastrophisieren, passives Krankheitsmodell), die Identifikation und der Abbau operanter (Krankheits-) Verstärkung sowie die Bearbeitung emotionaler Beeinträchtigungen (Depression). Vor und nach dem Programm sowie 6 und 12 Monate später wurden diese Patienten im Hinblick auf eine Veränderung sozialer, psychologischer, medizinischer und funktioneller Daten untersucht.ErgebnisseBis auf die Arbeitszufriedenheit und die dritte Form die Krankheitsbewältigung “kognitive Kontrolle” kam es über die Meßzeitpunkte bei allen anderen klinisch-psychologischen Variablen jeweils zu signifikanten Verbesserungen, die für die meisten Parameter im Laufe der Katamnesezeit stabil blieben. Anhand von Regressionsanalysen erfolgte eine differenzierte Beschreibung psychologischer Zusammenhänge für das Ausmaß des subjektiven Beeinträchtigungserlebens (Disability, 3 Parameter) und der 3 faktoriellen Formen der Krankheitsbewältigung des FEKB (Rumination, Informationssuche, kognitive Kontrolle). Die Operationslisierungen der ‘Disabilit’ zeigten nur geringfügige statistische Zusammenhänge zu Variablen der Schmerzbeschreibung, zu körperlichen Befunden und zu den erfaßten Formen der Krankheitsbewältigung. Dies ist ein Hinweis darauf, daß sich im “Disability-Erleben” vorrangig subjektive Patientenbewertungen widerspiegeln. Die Ergebnisse legen in der psychometrischen Diagnostik von Rückenschmerzpatienten eine konzeptuelle Trennung unterschiedlicher Merkmals-bereiche nahe, wobei das “Disability-Er. leben” eine eigenständige Komponente in der Beschreibung darstellt.SchlußfolgerungDie Analyse der Formen der Krankheitsbewältigung machte deutlich, daß es sich hier vermutlich eher um generalisierte Einstellungen zu Krankheit und Gesundheit handelt und nicht um spezifische (und damit veränderbare) Einstellungen bzw. Verhaltens-dispositionen in bezug auf Rücken-schmerzen. Nach den Ergebnissen der Untersuchung muß bezweifelt werden. ob das generelle Konzept der Krank-heitsbewältigung einen relevanten Beitrag zur Identifikation von modulierenden Faktoren bei chronischen (Rücken) Schmerzen leisten kann. Die in der vorliegenden Operationalisierung gefundenen Formen der Krankheitsbewältigung zeigten eine eher geringe Veränderung über die Zeit und zeichnete sich durch eine “Trait-Charakteristik” aus. Die Einordnung der Merkmalsbereiche “Disability” und “Krankheitsbewältigung” in das sog. “Fear-avoidance-Konzept” bringt möglicherweise weitergehendere Erkenntnisse über Chronifizierungsbe-dingungen bei Rückenschmerzen.AbstractProblemThe majority of authors agree today that psychosocial factors have more influence on a successful treatment of chronic back pain than other variables, in particular medical findings. Therefore treatments aim to integrate psychotherapeutic intervention in order to lessen emotional impairment, to change behavioral patterns (which advocate rest and the avoidance of physical activity), and to change cognitive attitudes and fears concerning exercise and work ability. Nevertheless, the interplay of cognitive measures and disability in treatment programs still remains an unclear issue.MethodsNinety disabled patients with chronic low back pain were admitted to an 8-week outpatient program of functional restoration and behavioural support. The program consisted of a pre-program (education, stretching and calisthenic exercises) and an intensive treatment period (physical exercises, back school education, cognitive behavioral group therapy, relaxation training, occupational therapy, vocational counseling), which took place for 5 weeks, 7 h a day, as an outpatient program. The targets of the psychological interventions were (a) to change maladaptive behavior (inactivity, social withdrawal) and increase the patient’s activity level at home, (b) to alter maladaptive cognitions (somatization, catastrophizing, passive expectations concerning treatment) and to improve their own positive coping skills, (c) to identify and stop operant conditioned behavior, and (d) to prevent depressive symptoms and strengthen the level of emotional control. The program’s philosophy encouraged the patients’ active efforts to improve their functional status within a therapeutic environment that reinforced positive behavior traits conductive to getting well. The main therapeutic target was to facilitate a return to work. Apart from a medical examination and a personal interview, the patients’ physical impairment, pain descriptions, and psychological distress (according to different criteria for evaluation) were also measured. This included variables such as depression, psychovegetative complaints, quality of life and workplace satisfaction, disability, and coping with disease. Measurements were repeated at the end of the 8-week program, and following 6- and 12-month intervals.ResultsIn comparison with the initial values, a statistically significant improvement became evident in reducing pain, disability, depression, and psychovegetative signs (P<0.001). Nearly all results remained stable at the 6- and 12-months examinations. Apart from these results, coping measurements demonstrated little improvement in the three factorial coping dimensions. By use of regression analyses, a differentiated description of psychosocial connections became apparent in three different ways of coping (catastrophizing, searching for information, cognitive control) and parameters of disability. Disability levels corresponded poorly with pain descriptions, physical impairment and coping dimensions. This result indicates that disability should be viewed as a separate component in assessing the patients’ description of low back pain.ConclusionAn analysis of coping dimensions demonstrated that current cognitive measures might be too general to explain low back disability adequately. In addition, the results indicate that the use of the ‘catastrophizing’ factor as a separate variable is questionable, since it may simply be a symptom of depression. The relevance of coping as a sensitive parameter for change is also addressed. It is suggested that an alteration in coping strategies may be an important treatment effect, but is subject to individual prerequisites to maximize treatment response. Thus, future research must focus on the complex interactions between personality variables, environmental factors, and the coping demands posed by the specific nature of pain problems. A more lengthy evaluation of socalled ‘fear-avoidance beliefs’ in combination with ‘disability’ and coping dimensions could possibly lead to further treatment on the development of chronicity in chronic low back pain patients.

Erste Ergebnisse eines multimodalen Behandlungsprogrammes für Patienten mit chronischen Rückenschmerzen Das Göttinger Rücken Intensiv Programm

ZusammenfassungIn AnbetrachtzunehmenderInzidenzundwachsenderKosten, die durch das Krankheitsbild ”Rückenschmerz“ verursacht werden, besteht ein dringendes Bedürfhis nach effektiven Behandlungsmethoden unter Berücksichtigung somatischer, psychologischer und sozialer Faktoren. Es wird ein Behandlungsprogramm für Patienten mit chronischen Rückenschmerzen vorgestellt, bei dem die körperliche Aktivität und Mitarbeit der Patienten im Vordergrund stent und sich das therapeutische Ziel weniger auf Schmerzfreiheit bzw. -reduktion beschränkt, sondern Aspekte wie eine bessere Selbstkontrolle der Beschwerden, die Übernahme von Verantwortung für die eigene Gesundheit und eine schnellere Reintegration in den Arbeitsprozeβ umfaβt. Erste Ergebnisse zeigen die Effektivität dieses Vorgehensnichtnurin bezugaufdiesubjektive Einschätzung der Patienten, sondern auch im Hinblickaufobjektivierbarefunktionelle somatische und psychologische Parameter some insbesondere auch hinsichtlich der Wiederherstellung der Arbeitsfähigkeit. Die Ergebnisse werden im Hinblick auf die prognostische Wertigkeit verschiedener Parameter diskutiert.AbstractThe incidence of low back pain is constantly increasing causing tremendous costs for the health insurance system. Therefore effective treatment methods taking into account somatic, psychologic and social factors are needed. A multimodal treatment program for chronic low back pain is presented, where physical activity and cooperation of the patient are the primary target points. The therapeutic aims are less focussed on pain reductionbutonpaincontrol,engaginginthepatients’ responsibility for themselves and an early reintegration in the working process. The first results demonstrate the high effectiveness of the multimodal program not only due to a positive change in somatical, psychological and physical variables but also in the number of patients who returned to work. Preliminary considerations about the prognostic value of differerent variables are discussed.

Intertester Reproducibility of the Isokinetic LIDO-Back System

Context: Trunk flexion and extension in normal participants using the Biodex and a LIDO-Back isokinetic trunk dynamometer. Objective: Assessment of interreproducibility of the isokinetic LIDO-Back system. Design and Setting: Intertester reproducibility study in a tertiary-care center (outpatient rehabilitation). Participants: 10 healthy individuals (4 women and 6 men) with a mean age of 29 years. Main Outcome Measures: Intertester reproducibility correlations of the isokinetic LIDO-Back. Measurements of 2 therapists were calculated using intraclass correlation coefficient (ICC1,1). Results: For the flexion parameters the ICCs were between .86 and .98, and for extension, between .63 and .78. Conclusions: A high intertester reproducibility relating to measurements of the LIDO-Back isokinetic trunk dynamometer was demonstrated. Intertester-reproducibility studies should become a routine method in the rehabilitation process.